Trigger Point and Tender Point Injections

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. Tender points also produce local pain when stimulated but lack the taut band of tissue and hyperirritability when palpated. Injection of an anesthetic agent or botulinum toxin into trigger points and tender points is being evaluated for the management of a variety of pain syndromes.

Related Policies:

Intravenous Anesthetics for the Treatment of Chronic Pain

***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

BCBSNC may provide coverage for Trigger Point and Tender Point Injections when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

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 Trigger Point and Tender Point Injections are covered

Trigger point injections with anesthetic and/or corticosteroid may be considered medically necessary for the treatment of myofascial pain syndrome when all of the following criteria have been met:

• There is a regional pain complaint in the expected distribution of referral pain from a trigger point, AND
• There is spot tenderness in a palpable taut band in a muscle, AND
• There is restricted range of motion, AND
• Conservative therapy (eg, physical therapy, active exercises, ultrasound, heating or cooling, massage, activity modification, or pharmacotherapy) for 6 weeks fails or is not feasible, AND
• Trigger point injections are provided as a component of a comprehensive therapy program, AND
• No more than 4 injections are given in a 12-month period.

When Trigger Point and Tender Point Injections are not covered

Trigger point and tender point injections are considered investigational for all other indications, including the treatment of myofascial pain syndrome not meeting the criteria above, complex regional pain syndrome, abdominal wall pain, and fibromyalgia.

Ultrasound and other imaging guidance of trigger point injections are considered investigational.

Policy Guidelines

For individuals who have myofascial pain syndrome who receive trigger point injections, the evidence includes several randomized controlled trials (RCTs) and a systematic review of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Lidocaine injections have been compared with physical therapy, lidocaine patches, sham stimulation, and dry needling. Some trials have reported that injecting lidocaine into trigger points improves subjective pain ratings to the same degree as physical therapy or lidocaine patches but only slightly more than sham stimulation. Other trials have found that lidocaine injection was superior to dry needling on subjective pain ratings but there was no significant benefit with lidocaine injection assessed on objective outcome measures. These results suggest a strong placebo effect of the treatment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have complex regional pain syndrome who receive trigger point injections, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Evidence on treatment of complex regional pain syndrome with trigger point injections is very limited, with only case series published and no recent literature identified for this treatment approach. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have abdominal wall pain who receive trigger point injections, the evidence includes an RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The single RCT evaluated lidocaine injections in women who had chronic pelvic pain and abdominal wall trigger points. Additional study in a larger population is needed to permit greater certainty about the efficacy of this treatment approach. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have fibromyalgia who receive tender point injections, the evidence includes an RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatmentrelated morbidity. The single RCT identified evaluated the efficacy of lidocaine injections in patients with fibromyalgia. It found a strong placebo effect, with lidocaine injection being not more effective than saline at reducing fibromyalgia pain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Treatment

Trigger point injections with local anesthetic, saline, steroid, or botulinum toxin type A are a potential treatment for pain associated with trigger points. Alternative nonpharmacologic 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.

Myofascial Pain Syndrome 

Myofascial pain syndrome is a chronic regional pain disorder caused by the activation of at least pne trigger point in muscles, tendons, or muscle fascia. It can cause local or referred pain, tightness, tenderness, stiffness and limitation of movement, muscle weakness, and often autonomic phenomena. The severity of symptoms and degree of functional impairment vary. Some individuals will have few trigger points with mild symptoms and no functional impairment, while others will have multiple satellite trigger points, widespread and severe pain, and major functional impairments. Conditions that can lead to myofascial pain syndrome include chronic repetitive minor muscle strain, poor posture, systemic disease, strain, sprain, enthesopathy, and arthritis. Management of chronic myofascial pain typically includes behavioral and pharmacologic approaches and physical therapy. Injection of a local anesthetic or botulinum toxin has also been reported.

Complex Regional Pain Syndrome

Complex regional pain syndrome (previously called sympathetic dystrophy) refers to a chronic and disabling condition characterized by persistent pain that is disproportionate to the extent and duration of the primary injury and is not restricted to the distribution of a specific peripheral nerve. Complex regional pain syndrome occurs most commonly following wrist fracture but may follow many other types of injury, even when the preceding injury is relatively minor. Complex regional pain syndrome may also occur when there is no known injury. Complex regional pain syndrome is classified into type I when a specific nerve lesion has not been identified and type II when there is an identifiable nerve lesion. The pain may consist of thermal or mechanical allodynia (pain that occurs from a stimulus that normally does not elicit a painful response such as light touch or warmth) dysesthesia (a constant or ongoing unpleasant or electrical sensation of pain), and / or hyperalgesia (an exaggerated response to normally painful stimuli). Management of complex regional pain syndrome includes oral and topical pharmacotherapy, physical therapy, psychological therapies, and interventional procedures such as regional anesthetic blocks, sympathetic blocks, or spinal cord stimulation. Amputation of the affected limb has also been performed.

Abdominal Wall Pain

A source of chronic abdominal wall pain is anterior cutaneous nerve entrapment syndrome, which typically presents as sharp and focal abdominal pain, and is often found near a scar. One hypothesis is that anterior cutaneous nerve entrapment syndrome results from the entrapment and ischemia of an anterior cutaneous branch of a thoracic nerve as it passes through the rectus abdominus muscle. Anterior wall pain can be distinguished from intra-abdominal pain by documenting that pain increases with maneuvers that tense the abdominal muscles. It has also been proposed that abdominal wall pain may be due to a myofascial trigger point in the rectus abdominus muscle.

Fibromyalgia

Fibromyalgia is a chronic condition characterized by widespread pain with hyperalgesia and allodynia. Constitutional symptoms such as fatigue, impaired cognition, and disrupted sleep can also occur. Early diagnostic criteria for fibromyalgia (1990) included three or more months of widespread pain above and below the waist, on both sides of the body, and along the midline, with at least 11 of 18 specific tender points. The defined bilateral areas from the American College of Rheumatology criteria are occipital, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knee medial fat pad. However, 2010 diagnostic criteria from the College, which were designed to facilitate diagnosis in a general practice setting, did not include a tender point exam but instead relied on the presence of widespread pain and other symptoms.

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: 20552, 20553

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and / or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.  

Scientific Background and Reference Sources

For Policy Titled: Neural Therapy

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 12/8/2011

Medical Director – 3/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 12/13/2012

Specialty Matched Consultant Advisory Panel – 1/2013

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 12/12/2013

Specialty Matched Consultant Advisory Panel – 1/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 12/11/2014

Specialty Matched Consultant Advisory Panel – 1/2015

Medical Director review – 1/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 12/10/2015

Specialty Matched Consultant Advisory Panel 1/2016

Medical Director review 1/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 11/9/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 11/8/2018

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 11/14/2019

Specialty Matched Consultant Advisory Panel 04/2020

American Association of Orthopaedic Medicine. Neural Therapy. 2013; http://www.aaomed.org/Neural-therapy. Accessed September, 2019

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.85, 11/12/2020

Specialty Matched Consultant Advisory Panel 04/2021

Medical Director review 4/2021

North American Spine Society. Diagnosis and treatment of low back pain. 2020. Accessed October 25, 2021

American Association of Orthopaedic Medicine. Neural Therapy. 2013; http://www.aaomed.org/Neural-therapy. Accessed October 25, 2021.

Specialty Matched Consultant Advisory Panel 04/2022

Medical Director review 4/2022

Frank BL. Neural therapy. Phys Med Rehabil Clin N Am. Aug 1999; 10(3): 573-82, viii. PMID 10516978

Specialty Matched Consultant Advisory Panel 04/2023

Medical Director review 4/2023

Specialty Matched Consultant Advisory Panel 04/2024

Medical Director review 4/2024

For Policy Titled: Trigger Point and Tender Point Injections

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

O'Connell NE, Wand BM, McAuley J, et al. Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database Syst Rev. Apr 30 2013; 2013(4): CD009416. PMID 23633371

Alnahhas MF, Oxentenko SC, Locke GR, et al. Outcomes of Ultrasound-Guided Trigger Point Injection for Abdominal Wall Pain. Dig Dis Sci. Feb 2016; 61(2): 572-7. PMID 26320087 Sumpton JE, Moulin DE. Fibromyalgia. Handb Clin Neurol. 2014; 119: 513-27. PMID 24365316

Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). May 2010; 62(5): 600-10. PMID 20461783

Medical Director Review 9/2024

Policy Implementation / Update Information

For Policy Titled: Neural Therapy

4/17/12 New policy. Neural therapy is considered investigational for all indications. Notification given 4/17/12. Policy effective 7/24/12. (btw)

1/29/13 Specialty Matched Consultant Advisory Panel review 1/16/2013. No change to policy intent. Reference added. (btw)

2/11/14 Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to policy. Reference added. (btw)

2/24/15 References updated. Specialty Matched Consultant Advisory Panel review 1/2015. Medical Director review 1/2015. Policy Statement unchanged. (td)

2/29/16 Policy Guidelines section revised References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016. (td)

12/30/16 Specialty Matched Consultant Advisory Panel review 11/30/2016. No change to policy statement. (an)

5/26/17 Specialty Matched Consultant Advisory Panel review 4/26/2017. No change to policy statement. (an)

6/8/18 Minor changes to Description and Policy Guidelines sections. Specialty Matched Consultant Advisory Panel review 5/23/2018. No change to policy statement. (an)

4/30/19 Minor changes to Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement. (an)

4/28/20 References added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement. (eel)

5/18/21 References added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement. (bb)

5/3/22 References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. (tt)

5/2/23 Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. (tt)

5/1/24 References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. (tt)

For Policy Titled: Trigger Point and Tender Point Injections

10/1/24 Policy re-titled to “Trigger Point and Tender Point Injections”. Policy statement updated to BCBSNC may provide coverage for Trigger Point and Tender Point Injections when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. When covered section updated to add medical necessity criteria. Description, Policy Guidelines, and References updated. Added 20552 and 20553 to Billing / Coding section. Notification given 10/1/2024 for effective date 12/31/2024.