Clinical UM Guideline |
Subject: Trigger Point Injections | |
Guideline #: CG-SURG-17 | Publish Date: 06/28/2024 |
Status: Reviewed | Last Review Date: 05/09/2024 |
Description |
This document addresses trigger point injections.
Trigger points are small, circumscribed, hyperirritable foci in muscles, often found within a firm or taut band of skeletal muscle. Frequently affected sites include the trapezius, supraspinatus, infraspinatus, teres major, lumbar paraspinals, gluteus and pectoralis muscles. The diagnosis is clinical and depends upon the results of a detailed history and a thorough directed exam. There is no laboratory or imaging test to establish the diagnosis of trigger point pain.
Myofascial pain syndrome is a regional painful muscle condition with a relationship between a specific trigger point and its associated pain region. When myofascial pain syndrome is suspected, injections of local anesthetics with or without steroid into the identified trigger points have been used for myofascial pain management for many years within the medical community.
Note: This document does not address the following types of trigger point injections:
Please refer to the applicable documents used by the plan for these services.
Clinical Indications |
Medically Necessary:
Not Medically Necessary:
Coding |
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
CPT |
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20552 | Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) |
20553 | Injection(s); single or multiple trigger point(s), 3 or more muscles |
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ICD-10 Diagnosis |
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G44.201-G44.229 | Tension-type headache |
G89.0 | Central pain syndrome |
G89.11-G89.18 | Acute pain, not elsewhere classified |
G89.21-G89.29 | Chronic pain, not elsewhere classified |
G89.4 | Chronic pain syndrome |
M25.50-M25.59 | Pain in joint |
M26.621-M26.629 | Arthralgia of temporomandibular joint |
M54.2 | Cervicalgia |
M54.50-M54.59 | Low back pain |
M70.80-M70.99 | Other/unspecified soft tissue disorders related to use, overuse or pressure |
M79.10-M79.18 | Myalgia (myofascial pain syndrome) |
M79.601-M79.676 | Pain in limb, hand, foot, fingers and toes |
M79.7 | Fibromyalgia |
When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed, or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Although not supported by rigorous randomized controlled trials (Cummings 2001), trigger point injections with a local anesthetic with or without a steroid are considered an accepted therapy for pain associated with myofascial pain syndrome or fibromyalgia syndrome.
In a Cochrane review, Peloso and colleagues (2011) examined the effects of medication and injections on primary outcomes (for example, pain) for adults with mechanical neck disorders and whiplash. In their data analysis, they found that lidocaine injection into myofascial trigger points appears effective in two trials.
In another Cochrane review, Staal and colleagues (2011) performed a data analysis to determine if injection therapy is more effective than placebo or other treatments for individuals with subacute or chronic low-back pain. Based on these results, the review authors concluded that there is no strong evidence for or against the use of any type of injection therapy for individuals with subacute or chronic low-back pain.
Kim and colleagues (2012) evaluated the therapeutic effectiveness of trigger point injections into the muscles around the groin in males with clinically diagnosed chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS). A total of 21 participants ranging in ages from 20 to 61 years met the inclusion criteria. The National Institute of Health- Chronic Prostatitis Symptom Index (NIH-CPSI) score and the visual analog scale for pain (VAS) were the main outcome measurements. Trigger point injections were performed in all affected muscles at 1-week intervals. Additional injections were not considered if the participants were satisfied with the reduction in discomfort or the severity of pain, or if the individual did not want another injection for other reasons. No other therapies (such as physical therapy or medications) were allowed during the study period. However, self-exercise and behavior correction were allowed to avoid early recurrence of pain after trigger point injections. All participants completed the treatment schedule and attended a follow-up, 66.7% (14/21) received 1 trigger point injection, 28.6% (6/21) received 2 injections and 1 participant received 3 injections. The majority of participants (19/21) reported symptom improvement and no need for further treatment. The treatment module was not completed by 2 participants, citing personal reasons. The VAS and NIH-CPSI scores decreased compared to baseline in all participants. There were no reported associated complications or serious adverse events. The authors concluded that US-guided trigger point injections of the iliopsoas, hip adductor, and abdominal muscles are safe and effective for CP/CPPS groin pain which is believed to originate from muscles. The iliopsoas muscle was affected in all of the participants in this study. The authors acknowledged that limitations of this study include its small size and short follow-up time.
Fernández-de-Las-Peñas (2018) published a consensus report on the diagnostic criteria for myofascial trigger points resulting from a Delphi panel of 60 experts from 12 countries. The results reported that at least two of the following diagnostic trigger point criteria must be present for a proper diagnosis: 1) a taut band, 2) a hypersensitive spot, and 3) referred pain. They noted that pain referral from a myofascial trigger point may include different sensory sensations, including pain spreading to a distant area, deep pain, dull ache, tingling, or burning pain. They proposed the use of the term “referred sensation” as an addition to “referred pain”.
Nouged and associates (2019) published a meta-analysis evaluating the effectiveness of local anesthetic trigger point injections in adults with myofascial pain syndrome of the head, neck or shoulder. The authors compared the trigger point injections to dry needling or placebo. A total of 11 randomized control trials (RCTs) were included in the meta-analysis. Participants of all included studies had a diagnosis of myofascial pain. The primary outcome measure was pain assessed using a VAS. In a comparison of double-blind studies, the improvement in VAS post-treatment in the trigger point injection sample compared to the dry needling sample was not statistically significant. While the trigger point injection group post-treatment VAS scores did show an improvement over placebo, the difference did not reach clinical significance. There are several limitations associated with this study. Sample sizes were small with heterogeneous populations, provider types, muscles treated, and interventions used. Risk of bias was judged to be high in 10 of the 15 included studies. Many of the studies did not control for the use of and adherence to concurrent therapies. The authors note:
The findings support the common practice of utilizing TrP [trigger point] injections after failure of noninvasive treatment modalities such as patient education, change in lifestyle, physical therapy, and medications; however, additional studies with larger numbers of participants, clearly monitored home treatments, and minimal risk of bias are needed to confirm these results.
The American College of Rheumatology (ACR) has published a series of recommendations regarding the diagnostic criteria for fibromyalgia (Wolfe, 1990, 2010, and 2016). The latest version, published in 2016, reflects an evolution in the understanding of this condition. Their recommendations are composed or two main components; the symptom severity scale (SSS) scale, which permits the evaluation of the severity of fibromyalgia symptoms, and the Widespread Pain Index (WPI) score which is a self-reported measure that is used to assess pain distribution in addition to the severity of six pain-specific symptoms. These symptoms include fatigue, memory difficulties, tiredness, headache, abdominal pain, and depression.
The SSS score is a calculated by adding the sum total of severity levels for 3 symptom groups over the past week (fatigue, feeling unrefreshed upon awaking and symptoms involving cognition) in addition to the extent (severity) of somatic symptoms in general. The final score will range from 0 to 12. The first component of the SSS, the symptom measures, are measured on a scale of 0-3:
The WPI score is determined by noting the number of pre-specified areas in which the individual has had pain during the last week (the total number of areas in which the individual has had pain). The cumulative score will be between 0 and 19. The areas are divided into 5 body areas and include the following:
The fibromyalgia severity (FS) scale is the sum of the WPI and SSS. The FS scale is also known as the polysymptomatic distress (PSD) scale.
Myofascial pain can be associated with both acute and chronic pain and frequently is present with other acute or chronic musculoskeletal conditions. Myofascial pain is typically treated using a variety of modalities including trigger point injections and “physical therapy, postural or ergonomic correction, and treatment of underlying musculoskeletal pain generators” (Lam, 2024). Trigger point injections are a widely used intervention for myofascial pain which has been refractory to conventional treatment. While the exact mechanism of action is unknown, trigger point injections are categorized as a low-risk medical procedure which can be appropriate as a means of disrupting the pain-tension cycle. There are no current clinical guidelines or recommendations which advocate for the administration of trigger point injections as a recognized therapeutic intervention in individuals who have previously undergone a regimen of trigger point injections, irrespective of the response elicited by such treatments.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Fibromyalgia
Myofascial Pain
Trigger Point
History |
Status | Date | Action | |||
Reviewed | 05/09/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Discussion and References sections | |||
Reviewed | 05/11/2023 | MPTAC review. Updated Discussion and References sections. | |||
Revised | 05/12/2022 | MPTAC review. Clarification of the trigger point injection MN general criteria. Revised MN statement for fibromyalgia treatment. Moved measurement scale information and specialty society recommendations to the Discussion section. Updated Discussion and References sections. | |||
| 10/01/2021 | Updated Coding section with 10/01/2021 ICD-10-CM changes; added M54.50-M54.59 replacing M54.5 deleted 09/30/2021. | |||
Reviewed | 05/13/2021 | MPTAC review. Updated Discussion and References sections. Reformatted Coding section and added diagnosis codes. | |||
Reviewed | 05/14/2020 | MPTAC review. Updated References. | |||
Revised | 06/06/2019 | MPTAC review. Revised document so that it no longer addresses dry needling. Updated the Description, Clinical Indications, Coding, Discussion/General Information, References and Index sections by removing information related to dry needling. | |||
Reviewed | 03/21/2019 | MPTAC review. Updated review date and History sections. | |||
Reviewed | 05/03/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated review date, Rationale, References and History sections. | |||
Revised | 05/04/2017 | MPTAC review. Updated formatting in the Clinical Indications section. In the Not Medically Necessary statement, inserted the word “or” after bullets IA and IB. Updated review date, Coding, and History sections. | |||
Reviewed | 05/5/2016 | MPTAC review. Updated review date, References and History sections. | |||
| 01/01/2016 | Updated Coding section with 01/01/2016 descriptor change for CPT 20553; removed ICD-9 codes. | |||
Revised | 05/07/2015 | MPTAC review. Expanded the medically necessary criteria for trigger point injections for individuals with fibromyalgia to include the 2010 ACR criteria. Updated review date, Discussion/General Information, References and History sections. | |||
Reviewed | 05/15/2014 | MPTAC review. Updated References section. | |||
Reviewed | 05/09/2013 | MPTAC review. Updated Discussion/General Information and References sections. | |||
Reviewed | 05/10/2012 | MPTAC review. Discussion and References sections updated. | |||
Reviewed | 05/19/2011 | MPTAC review. References and Coding sections updated. | |||
Reviewed | 05/13/2010 | MPTAC review. References section updated. | |||
Reviewed | 05/21/2009 | MPTAC review. Discussion and References sections updated. Place of service removed. | |||
Reviewed | 05/15/2008 | MPTAC review. References section updated. | |||
Revised | 05/17/2007 | MPTAC review. Guideline revised to address dry needling. Background, Coding, and References section updated. | |||
Reviewed | 12/07/2006 | MPTAC review. References section updated. | |||
Revised | 12/01/2005 | MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
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Pre-Merger Organizations | Last Review Date | Document Number | Title | ||
Anthem, Inc. |
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| None | ||
Anthem BCBS |
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| None | ||
WellPoint Health Networks, Inc. | 12/02/2004 | Guideline | Regional Anesthesia/Pain Management for Chronic Neck, Back and Myofascial Pain |
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