Trigger Point Injections

Jurisdiction: J5 MAC Part B. States: Iowa, Kansas, Missouri, Nebraska. Type: Active LCD

Initial Trigger Point Injection (TPI) Trigger point injections will be considered medically reasonable and necessary to treat myofascial pain caused by trigger points when all the following requirements are met: There is a focal area of pain in the skeletal muscle. There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with a at least 2 of the following: a hyperirritable spot and/or taut band identified by palpation and possible referred pain is present AND The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain AND Non-invasive conservative therapy is not successful as first line treatment OR movement of a joint or limb is limited or blocked OR the TPI is necessary for diagnostic confirmation. Subsequent TPI Repeat Trigger point injections will be considered medically reasonable and necessary to treat myofascial pain syndrome when all the following requirements are met: There is a positive response defined as providing a minimum of 50% relief of primary (index) pain after the TPI measured by the same pain scale* at baseline and post-injection AND Consistent pain relief from previous TPI lasting at least 6 weeks 1 AND The pain has reoccurred and is causing functional limitations measured by functional scale obtained at baseline and after TPI which demonstrates at least 50% functional improvement from the previous TPI. *Note: The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scale (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function. Limitations: No more than three (3) TPI sessions will be reimbursed per rolling 12 months. Requirements: Patient should be part of an ongoing conservative treatment program, and documentation to support the patient is actively participating in a rehabilitation program, home exercise program or functional restoration program. Trigger point primary index pain must be measured prior to the injection at the beginning of the session. The post procedure pain level must be measured after the TPI at the conclusion of the session using the same pain scale* utilized at baseline. When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief. The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the same pain scale* used at baseline. When documenting the ability to perform previously painful movements and activities of daily living (ADLs) it is insufficient to provide a vague or nonspecific statement regarding the improvement of previously painful movements and activities of daily living (ADLs). The documentation should include a functional assessment to show clinically meaningful improvement with painful movements and ADLs, if this metric is used to justify the efficacy of the TPI procedure. Providers should use established and measurable goals and objective scales to assess functionality and ADLs measures. Limitations: Trigger points injections with biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and/or any other injectate besides a local anesthetic are not considered medically reasonable and necessary. It is not considered medically reasonable and necessary to perform TPIs into multiple muscle groups in different anatomical regions during the same session. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks etc.) during the same session as TPIs injections. Trigger points injections for treatment of headache, neck pain or low back pain in absence of actual trigger points, diffuse muscle pain, chronic pain syndrome, lumbosacral canal stenosis, fibromyalgia, non-malignant musculoskeletal pain, complex regional pain syndrome, sexual dysfunction/ pelvic pain, whiplash, neuropathic pain, and hemiplegic shoulder pain are considered investigational and therefore are not considered medically reasonable and necessary. Use of fluoroscopy or MRI guidance for performance of TPIs is not considered reasonable and necessary. The use of ultrasound guidance for the performance of TPIs is considered investigational. Trigger point injections used on a routine basis, e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes are not considered medically necessary. Provider Qualifications: The Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers. Patient safety and quality of care mandate that healthcare professionals who perform TPI injections/procedures for chronic pain (not surgical anesthesia) are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program whose core curriculum includes the performance and management of the procedures addressed in this policy. Credentialing or privileges are required for procedures performed in inpatient and outpatient settings. 2 All aspects of care must be within the provider's medical licensure and scope of practice. Reimbursement for procedures utilizing imaging techniques may be made to providers who meet training requirements for the procedures in this policy only if their respective state allows such in their practice act and formally licenses or certifies the practitioner to use and interpret these imaging modalities (ionizing radiation and associated contrast material, magnetic resonance imaging, ultrasound). At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure, and utilization of the required associated imaging modalities. Definitions Acupuncture - Placement of (diameter/solid not thin) needles to strategic points in to treat pain and disease without injection of a medicine. Anatomical Region – An area of the body defined by structures which are palpable or visible. Typically described as cervical region, lumbar region, scapular region, thoracic region, cephalic region, facial region, etc. 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 – A system developed by the GRADE Working Group to address the shortcomings of present grading systems in healthcare. The GRADE system uses a common, sensible, and transparent approach to grading the quality of evidence. The results of applying the GRADE system to clinical trial data are displayed in a table known as a GRADE profile. Muscle group - a group of muscles that are contiguous and that share a common function, e.g., flexion, stabilization or extension of a joint. Muscles that are widely separated anatomically and have different functions may be considered to be separate muscle groups. Myofascial pain syndrome – a chronic pain syndrome characterized by trigger points associated with the development of peripheral and central sensitization. Nerve block - an invasive procedure where medication is injected directly into or around a nerve. Session – A time period, which includes all procedures (i.e., medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations) performed during 1 day. Tender Point - areas of tenderness occurring in muscles, muscle-tendon junction, bursa or fat pad. 3 Tendon sheath injection – an invasive procedure where medication is injected into a tendon sheath. Trigger point - pain in a skeletal muscle that is associated with a at least 2 of the following: a hyperirritable spot, taut band and referred pain. 3,4 Trigger point injection - an invasive procedure where typically a local anesthetic is injected directly into a trigger point. 5