Dry Needling of Myofascial Trigger Points

Description of Procedure or Service

Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain.

Dry needling refers to a procedure in which a fine needle is inserted into the skin and muscle at a site of myofascial pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The intent is to stimulate underlying myofascial trigger points, muscles, and connective tissues to manage myofascial pain. Dry needling may be performed with acupuncture needles or standard hypodermic needles, but is performed without the injection of medications (e.g., anesthetics, corticosteroids). Dry needling is proposed to treat dysfunctions in skeletal muscle, fascia, and connective tissue; diminish persistent peripheral pain; and reduce impairments of body structure and function.

The physiological basis for dry needling depends on the targeted tissue and treatment objectives. The most studied targets are trigger points. Trigger points can be visualized by magnetic resonance imaging and elastography. Reliability of manual identification of trigger points has not been established.

Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. This local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle, and has been associated with alleviation of spontaneous electrical activity; reduction of numerous nociceptive, inflammatory, and immune system related chemicals; and relaxation of the taut band. Deep dry needling of trigger points is believed to reduce local and referred pain, improve range of motion, and decrease trigger point irritability.

Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses. The physiological basis for dry needling treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not as well described in the literature.

Alternative nonpharmacological treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch.

Dry needling is considered a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Dry needling of trigger points for the treatment of myofascial pain is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Dry Needling of Myofascial Trigger Points is covered

Not applicable.

When Dry Needling of Myofascial Trigger Points is not covered

Dry needling of trigger points for the treatment of myofascial pain is considered investigational. 

Policy Guidelines

For individuals who have myofascial trigger points associated with neck and/or shoulder pain who receive dry needling of trigger points, the evidence includes randomized controlled trials and systematic reviews. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of techniques to treat myofascial pain included 15 studies of dry needling for neck or shoulder pain published through 2017. Studies had multiple methodological limitations, and the reviewers concluded that the evidence for dry needling was not greater than placebo. In more recent systematic reviews and meta-analyses, dry needling was not associated with clinically significant reductions in shoulder or neck pain when compared to other physical therapy modalities. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myofascial trigger points associated with plantar heel pain who receive dry needling of trigger points, the evidence includes a systematic review of randomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review included 6 randomized trials enrolling 395 patients and found no overall difference in pain intensity in those treated with dry needling compared with active control, placebo, or no intervention. However, pain intensity after at least 3 sessions, long-term pain intensity, and pain-related disability were improved. The systematic review rated the evidence as low to moderate. The evidence for dry needling in patients with plantar heel pain is limited by small patient populations and lack of blinding; therefore, additional RCTs are needed to strengthen the evidence base. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The evidence for individuals who have myofascial trigger points associated with temporomandibular pain who receive dry needling of trigger points, includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One double-blind, sham-controlled randomized trial was identified; it found that, 1 week after completing the intervention, there were no statistically significant differences between groups in pain scores or function (unassisted jaw opening without pain). There was a significantly higher pain pressure threshold in the treatment group. Additional RCTs, especially those with a shamcontrol group, are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 20560, 20561

Because dry needling is not acupuncture, CPT codes 97810-97814 are not appropriate.

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.100, 5/19/2016

Specialty Matched Consultant Advisory Panel review 11/2016

Medical Director review 11/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.100, 4/2017

Medical Director review 4/2017

Specialty Matched Consultant Advisory Panel review 09/2017

Medical Director review 09/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.100, 4/2018

Medical Director review 4/2018

Specialty Matched Consultant Advisory Panel review 09/2018

Medical Director review 09/2018

Specialty Matched Consultant Advisory Panel review 09/2019

Medical Director review 09/2019

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.100, 5/2020

Specialty Matched Consultant Advisory Panel review 09/2020

Medical Director review 09/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.100, 5/2021

Specialty Matched Consultant Advisory Panel review 09/2021

Medical Director review 09/2021

Specialty Matched Consultant Advisory Panel review 09/2022

Medical Director review 09/2022

Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. Feb 15 2002;65(4): 653-60. PMID 11871683

Charles D, Hudgins T, MacNaughton J, et al. A systematic review of manual therapy techniques, drycupping and dry needling in the reduction of myofascial pain and myofascial trigger points. J BodywMov Ther. Jul 2019; 23(3): 539-546. PMID 31563367

Navarro-Santana MJ, Sanchez-Infante J, Fernández-de-Las-Peñas C, et al. Effectiveness of DryNeedling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated SystematicReview and Meta-Analysis. J Clin Med. Oct 14 2020; 9(10). PMID 33066556

Navarro-Santana MJ, Gómez-Chiguano GF, Cleland JA, et al. Effects of Trigger Point Dry Needling forNontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. PhysTher. Feb 04 2021; 101(2). PMID 33340405

Para-García G, García-Muñoz AM, López-Gil JF, et al. Dry Needling Alone or in Combination withExercise Therapy versus Other Interventions for Reducing Pain and Disability in Subacromial PainSyndrome: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. Sep 02 2022;19(17). PMID 36078676

Llurda-Almuzara L, Labata-Lezaun N, Meca-Rivera T, et al. Is Dry Needling Effective for theManagement of Plantar Heel Pain or Plantar Fasciitis? An Updated Systematic Review and MetaAnalysis. Pain Med. Jul 25 2021; 22(7): 1630-1641. PMID 33760098

Bagcier F, Yilmaz N. The Impact of Extracorporeal Shock Wave Therapy and Dry Needling Combinationon Pain and Functionality in the Patients Diagnosed with Plantar Fasciitis. J Foot Ankle Surg. 2020;59(4): 689-693. PMID 32340838

Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain:a randomized controlled trial. Phys Ther. Aug 2014; 94(8): 1083-94. PMID 24700136

Eftekharsadat B, Babaei-Ghazani A, Zeinolabedinzadeh V. Dry needling in patients with chronic heelpain due to plantar fasciitis: A single-blinded randomized clinical trial. Med J Islam Repub Iran. 2016; 30:401. PMID 27683642

Rastegar S, Baradaran Mahdavi S, Hoseinzadeh B, et al. Comparison of dry needling and steroidinjection in the treatment of plantar fasciitis: a single-blind randomized clinical trial. Int Orthop. Jan 2018; 42(1): 109-116. PMID 29119296

Uygur E, Aktaş B, Eceviz E, et al. Preliminary Report on the Role of Dry Needling Versus CorticosteroidInjection, an Effective Treatment Method for Plantar Fasciitis: A Randomized Controlled Trial. J FootAnkle Surg. Mar 2019; 58(2): 301-305. PMID 30850099

Dıraçoğlu D, Vural M, Karan A, et al. Effectiveness of dry needling for the treatment oftemporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J BackMusculoskelet Rehabil. 2012; 25(4): 285-90. PMID 23220812

Specialty Matched Consultant Advisory Panel review 09/2023

Medical Director review 09/2023

Policy Implementation/Update Information

7/1/16 New policy created. “Dry needling of trigger points for the treatment of myofascial pain is considered investigational.” (sk)

12/30/16 New policy adopted. “Dry needling of trigger points for the treatment of myofascial pain is considered investigational. Specialty Matched Consultant Advisory Panel review 11/2016. Medical Director review 11/2016. (jd)

5/26/17 Referenced updated. Medical Director review 4/2017 (jd)

10/13/17 Specialty Matched Consultant Advisory Panel review 09/2017. Medical Director review 09/2017. (jd)

10/12/18 References updated. Specialty Matched Consultant Advisory Panel review 09/2018. Medical Director review 09/2018. (jd)

10/15/19 References updated. Specialty Matched Consultant Advisory Panel review 09/2019. Medical Director review 09/2019. (jd)

12/31/19 Added the following codes to the Billing/Coding section effective 1/1/20: 20560, 20561. (jd)

10/1/20 References updated. Specialty Matched Consultant Advisory Panel review 09/2020. Medical Director review 09/2020. (jd)

10/1/21 Minor update to policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 09/2021. Medical Director review 09/2021. (jd)

10/18/22 Policy guidelines and References updated. Specialty Matched Consultant Advisory Panel review 09/2022. Medical Director review. 09/2022. (tm)

10/10/23 Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 09/2023. Medical Director review. 09/2023. (tm)