Trigger Point Injections

Jurisdiction: JL MAC Part B. States: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania. Type: Active LCD

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. Contextual Policy Insights/Introduction Dry Needling- a technique that involves the insertion of solid filament needles into the skin and underlying tissue to disrupt pain sensory pathways and relax contracted fibers. Fibromyalgia – a chronic pain syndrome which presents with tender points, somatic symptoms and widespread musculoskeletal pain associated with the development of peripheral and central sensitization. GRADE – Grading of Recommendations Assessment, Development and Evaluation approach developed by the GRADE Working Group is a widely accepted framework for rating certainty of evidence and strength of recommendations. Myofascial Pain Syndrome – a chronic pain syndrome characterized by myofascial trigger points associated with the development of peripheral and central sensitization. Myofascial pain syndrome is often associated with trigger points, and it is a common musculoskeletal disorder characterized by localized muscle pain and tenderness with hyperirritable spots within the muscle tissue or fascia. PICO Question – a framework of focused clinical questions using the components: Patient/Population/Problem, Intervention, Comparison, and Outcome. Session – an encounter which includes all TPI performed on the same date of service. Tender Point- areas of tenderness occurring in muscles, muscle-tendon junction, bursa or fat pad. Trigger Points - discrete, focal, hyperirritable spots located within a taut band of skeletal muscle. Trigger Points can produce local pain and referred pain symptoms and often accompany chronic musculoskeletal disorders. The patients may have persistent pain which could potentially result in a decreased range of motion in the affected muscles. The physical exam findings typically associated with a trigger point is the palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal surrounding tissue. 1,8 Palpation of the trigger point will elicit pain directly over the affected area and potentially have radiating pain and a local twitch response. 8 Trigger points can be diagnosed by history and physician examination; therefore, a consistent and reproducible physical examination technique is critical for clinical management. 9 Borg Stein et al proposed major and minor criteria to define the trigger point. 9 Diagnosis is considered most likely when all the major criteria are present; however, the minor criteria are supportive, particularly in cases where there is uncertainty regarding the classification of a painful area as a tender point versus a trigger point. Criteria proposed are the following: Major Criteria: Regional pain complaints, Focal pain to palpation, Pain referred to a regional site, Reproduction of pain complaints Minor Criteria: Presence of a taut band, Local twitch response elicited by needle insertion into the trigger point, decreased range of motion of the involved muscle Trigger Point Injection (TPI) - an invasive procedure where medication is injected directly into a trigger point. The mechanism of action of these injections is thought to be disruption of the trigger points by the mechanical effect of the needle or the chemical effect of the agents injected, resulting in relaxation and lengthening of the muscle fiber. The effect of the injectate may include local vasodilation, dilution, and removal of the accumulated nociceptive substrates. 10 TPI is indicated for patients who have symptomatic trigger points that produce a twitch response to pressure and create a pattern of referred pain. 8 Covered Indications Trigger Point Injections (TPI) will be considered reasonable and necessary to treat myofascial pain caused by a trigger point when the following requirements are met: There is a focal area of pain in skeletal muscle, directly associated with a palpable, firm nodule within a taut band of muscle fiber 1 AND Physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber which is palpable and more firm than normal consistency and surrounding muscle, with or without local twitch response and referred pain 1 AND Patients must be participating in a multimodal program with contemporaneous documentation supporting consistent, active participation in a prescribed pain management plan. Limitations The following are considered not reasonable and necessary: The use of ultrasound (US) guidance for performance of TPI. 3 The use of fluoroscopy or magnetic resonance imaging (MRI) guidance for performance of TPI (see rationale for determination). A TPI involves the use of local anesthetics (LA) and does not include the use of corticosteroids, saline, biologicals, prolotherapy, platelet rich plasma (PRP), botulinum toxin, and/or any other injectates. 2,3 (see Related National Coverage Documents) TPI for treating low back pain, 4,5 fibromyalgia, 6 or any other condition not meeting the diagnostic criteria for myofascial pain syndrome in absence of trigger points. 2 The routine performance of more than three (3) TPI sessions within a rolling 12-month period is not reasonable and necessary. In exceptional, clinically appropriate circumstances, a maximum of four (4) sessions may be justified. For such cases, providers must submit an attestation with the claim confirming that all coverage criteria outlined in this policy are met. Providers are advised to consult the Billing and Coding Article for guidance on attestation and documentation requirements. 13 Five (5) or more TPI sessions per rolling 12-month period per beneficiary. 7(pp21-29) Notice: Services performed for any given diagnosis must meet all the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.