Clinical Policy Title: Spine pain — trigger point injections

Clinical Policy Number: 03.03.05

Policy contains:
Effective Date: September 1, 2013
Initial Review Date: December 10, 2013  Trigger point injections.
Most Recent Review Date: February 6, 2018  Back pain.
Next Review Date: February 2019

Related policies:

CP# 03.03.01 Spinal cord stimulators for chronic pain

CP# 03.02.02 Radiofrequency ablation treatment for spine pain
CP# 03.03.03 Spinal surgeries
CP# 03.03.04 Spine pain — epidural steroid injection
CP# 03.02.07 Spine pain — facet joint injection

ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health
Choice’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS),
state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional
literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements,
including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by
Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state
or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control.
Prestige Health Choice’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment.
Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice’s clinical
policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical
policies as necessary. Prestige Health Choice’s clinical policies are not guarantees of payment.

Coverage policy

Prestige Health Choice considers the use of the trigger point injections of local anesthetics, alone or in
combination with corticosteroids, for the treatment of spine pain to be clinically proven and, therefore,
medically necessary, as part of a multimodal approach to pain management when the following criteria
are met (Manchikanti, 2001; Hayes, 2009; ASA/ASRTPM, 2010; ICSI, 2013):

Trigger points have been identified, and a comprehensive pain evaluation and treatment plan has been
developed by a qualified specialist trained in administering trigger point injections.
1. Noninvasive medical management (e.g., exercise; physical therapy; passive modalities such as
ice and heat; massage; and medications such as oral analgesia, muscle relaxants, and tricyclic

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 antidepressants) has been unsuccessful.

2. The frequency of TPIs is two months or longer between each injection.

3. The injections should only be repeated as necessary if the medical necessity criteria above are
achieved to a maximum of six treatments per rolling 12-month period, provided there is
documented evidence of functional improvement after the TPI and documented evidence of
decreased use of pain medications after the injections.

4. Re-evaluation of the diagnosis is recommended for patients who fail to improve after a series of
three trigger point injections.

Limitations:

Coverage determinations are subject to benefit limitations and exclusions as delineated by the state
Medicaid authority. The Florida Medicaid website may be accessed at
http://ahca.myflorida.com/Medicaid/.

Prestige Health Choice considers any of the following to be investigational and/or experimental:
 Trigger point injections for treatment of fibromyalgia without a myofascial pain component
characterized by local tenderness over taut muscle bands.
 Dry needle stimulation of trigger points.
 Trigger point injections with saline or glucose.
 Use of Botox® over trigger point injections.
 Trigger point injections for non-specific acute or chronic low back pain.
 Trigger point injections performed beyond eight months after initiation of treatment
without a documented re-evaluation of the member’s complaint.

Alternative covered services:

 Pharmacotherapy (e.g., non-narcotic analgesics and non-steroidal anti-inflammatory drugs

[NSAIDs]).
 Physical therapy, osteopathic manipulation, chiropractic manipulation.
 Medications, such as anti-inflammatory or analgesic drugs, laminectomy, and trigger point
or epidural injections.
 Surgical intervention (see policy 03.03.03 on spinal surgeries).

Background

Back pain is one of the most common causes of disability and pain. One-fourth of the adult U.S.
population reported back pain lasting at least one full day in the past quarter (Deyo, 2006). This was a

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similar incidence as had been reported in a study performed in the 1990s. The incidence and severity
was greater in populations with lower educational levels. Other estimates are that up to 80 percent of
the U.S. population will experience back pain at some point during their lives.

The incidence of chronic back pain increases with age and with poverty. Fortunately, the majority of
persons from all demographic backgrounds recover from the acute episodes. But some 20 percent of
members will have recurrence within a year. There has been a significant increase in costs for low back
pain, as well as a significant increase in diagnostic and therapeutic options available to patients with low
back pain.

Guidelines from medical professional societies and studies from the peer-reviewed medical literature
indicate many of the diagnostic and therapeutic services provided have evidence of effectiveness, while
other services have less evidence of effectiveness and may be harmful. This policy reviews the use of
trigger point injections in the treatment of spine pain.

Trigger point injections are the injection of local anesthetics or anti-inflammatory medications into
myofascial trigger points. Trigger points are self-sustaining irritative foci that occur in skeletal muscle in
response to strain, as well as mechanical overload phenomena. These trigger points produce a referred
pain pattern characteristic for the individual involved muscle.

Trigger point injections are an integral part of comprehensive pain management, and may be used
concurrently in support of other conservative modalities. Conservative therapy may include analgesics,
passive physical therapy, ultrasound, range of motion exercises, chiropractic intervention (within the
defined limits of the Medicare benefit), and active exercises. Additionally, trigger point injections may be
indicated when joint movement is mechanically limited, as in the case of the coccygeus muscle.

With no laboratory test criteria to identify trigger points available, the diagnosis of trigger points
requires a detailed history and thorough physical examination to treat the cause of pain, not just the
symptoms. With this intent, it is expected that trigger point injections may be performed as frequently
as every two months for a maximum total of six injections in a rolling 12-month period (ICSI 2013).
Thereafter, the patient should be re-evaluated regarding the etiology of the complaint, and the available
treatment options reconsidered.

Trigger point injections and dry needling into trigger points are typically more effective methods than
manual trigger point therapies. Trigger point injections are usually indicated for patients with active
trigger points that produce a twitch when pressure is applied to the area. Dry needling may result in a
more intense or longer lasting soreness of the injection site (Malanga, 2010).

Myofascial pain syndrome is a common non-articular local musculoskeletal pain syndrome caused by
myofascial trigger points located at muscle, fascia, or tendinous insertions, affecting up to 95 percent of
persons with chronic pain disorders. Myofascial pain syndrome can present as painful restricted range of
motion, stiffness, referred pain patterns, and autonomic dysfunction. The underlying cause is often

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related to muscular imbalances, and following a thorough physical examination the condition should be
treated with a comprehensive rehabilitation program. Additional treatment options include
pharmacology, needling with or without anesthetic agents or nerve stimulation, and alternative
medicine treatments, such as massage or herbal medicines. Repeated trigger point injections should be
avoided, and corticosteroids should not be injected into trigger points.

Searches

Prestige Health Choice searched PubMed and the databases of:

 UK National Health Services Centre for Reviews and Dissemination.
 Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
 The Centers for Medicare & Medicaid Services (CMS).

Searches were conducted on December 21, 2017, using the term “trigger point injections treatment.”

We included:
 Systematic reviews, which pool results from multiple studies to achieve larger sample sizes
and greater precision of effect estimation than in smaller primary studies. Systematic
reviews use predetermined transparent methods to minimize bias, effectively treating the
review as a scientific endeavor, and are thus rated highest in evidence- grading hierarchies.
 Guidelines based on systematic reviews.
 Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency
studies — which also rank near the top of evidence hierarchies.

Findings

A number of guidelines on treating various types of pain, including spine and back pain, make no
mention of trigger point injections, including the 2007 American College of Physicians and American Pain
Society guideline on low back pain (Chou, 2007).

Other guidelines are not able to recommend trigger point injections in pain management. The
Association of Neurological Surgeons and Congress of Neurological Surgeons 2005 guideline on
degenerative disease of the lumbar spine states there is “conflicting evidence suggesting use of local
trigger point injections can be effective for the short-term relief of low back pain” (Resnick, 2005). The
American Pain Society 2009 guideline finds insufficient evidence to recommend for or against local
injections (including trigger pain injections) for non-specific low back pain (Chou, 2009), due to the lack
of evidence of long-term efficacy, while acknowledging short-term improvements in pain levels
(Watters, 2010).

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An early American Society of Interventional Pain Physicians guideline covers the diagnosis of pain
through symptoms and establishing trigger points (Manchikanti, 2001). In addition, non-invasive medical
management should be attempted before considering trigger point injections, or these injections can be
used as a bridging therapy while other treatments are initiated (Hayes, 2009).

A guideline by the American Society of Anesthesiologists Task Force on Chronic Pain Management and
American Society of Regional Anesthesia and Pain Medicine found evidence for single modality
interventions for chronic pain, including trigger point injections, to be “insufficient to evaluate efficacy
to provide relief,” but can be considered for treatment of patients with myofascial pain as part of a
multimodal approach (ASA/ASRAPM, 2010).

Several systematic reviews have addressed trigger point injections’ impact on pain. A Hayes review of 17
randomized controlled trials (RCTs) of myofascial pain found that trigger point injections with various
anesthetics decreased pain levels 34 to 88 percent, roughly the same as the reduction from trigger point
injections with no injectate, also known as dry needle (31 to 87 percent). Hayes also found that trigger
point injections reduce pain compared to no treatment (Hayes, 2013).

A systematic review of 15 RCTs of chronic non-malignant musculoskeletal pain concluded trigger point
injections are safe, relieve symptoms when used as sole therapy for pain, and are useful as an adjunct to
intra-articular injection for osteoarthritis, but show “no clear evidence of either benefit or
ineffectiveness” (Scott, 2009). The same conclusion of no strong evidence for or against any type of
injection therapy for low back pain was reached in a Cochrane review (Staal, 2008). A systematic review
of botulinum toxin A injections in trigger points for myofascial pain found no consistent support for the
procedure, as data are limited and clinically heterogeneous (Ho, 2007).

The 2013 Hayes review included studies that addressed aspects of trigger point injection efficacy on
alleviating myofascial pain:
1. Trigger point injectionswith lidocaine and dry needling are both effective in reducing pain
(Ay, 2010; Eroglu, 2013; Ozkan, 2011).

2. There is a similar increase in range of motion for trigger point injections with lidocaine or
dry needling (Eroglu, 2013).

3. There is a 32 percent reduction in depression after 12 weeks among patients in pain after
trigger point injections with lidocaine, and a 17 percent reduction after dry needling (Ay,
2010).

4. The response (pain reduction) to therapy for trigger point injections with botulinum is 51
percent, significantly greater than placebo at 26 percent (Gobel, 2006).

A systematic review of five studies determined that botulinum toxin A used in myofascial Trigger Point
Injections was effective in pain relief for just one of the five studies (Ho, 2007).

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A study found the anesthetics levobupivacaine and ropivacaine for trigger point injections were equally
effective in reducing pain, with equal duration of pain reduction (Zaralidou, 2007).Another study of 98
patients with chronic pain and lumbosacral radiculopathy at L4 – L5 and L5 – S1 were examined for the
presence of trigger points in their lower extremities. Of the 64 patients with trigger points, 32 received
injections; their average pain score after treatment was 2.40, compared to 4.06 for the untreated group,
significant at p = 0.008 (Saeidian, 2014).

Acupuncture achieved similar pain relief and quality of life improvements to trigger point injections
(bupivacaine twice weekly, plus cyclobenzaprine chlorhydrate daily and sodium dipyrone every eight
hours) for myofascial trigger point pain (Gazi, 2011).

Some clinicians assert that trigger point injections should not be used at all for pain reduction. A 2015
review declares myofascial pain syndromes caused by trigger points are “inventions . . . with no scientific
basis” (Quintner, 2015). Another review states trigger point injections are not indicated for chronic low
back pain (Shen, 2006). Another states that repeated trigger point injections should be avoided, and
corticosteroids shouldn’t be injected into trigger points (Malanga, 2010). While acknowledging short-
term improvements in pain and/or disability by targeting trigger points, supporting insertion of dry
needles, another article states there is lack of robust evidence validating the clinical diagnostic criteria
for trigger point identification or diagnosis (Dunning, 2014).

Policy updates:

A total of one peer-reviewed reference was added to, and two guidelines/other and two peer-reviewed
references were removed from this policy in December 2017.

The January 2017 version of the policy included an additional six professional guideline/other
references, plus an additional 12 peer-reviewed references. The coverage section has been simplified.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Hayes (2013) Key points:

Trigger point injections for
myofascial pain
 Hayes review of 17 studies of trigger point injections.
 Trigger point injection with lidocaine and dry needling are both effective in reducing pain.
 Similar increases in range of motion observed for trigger point injection with lidocaine and
dry needling.
 A 32 percent reduction in depression observed after 12 weeks among patients in pain after
trigger point injection with lidocaine, and a 17 percent reduction after dry needling.
 The response (pain reduction) to therapy for trigger point injection with botulinum is 51%,
significantly greater than placebo (26%).

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 Citation Content, Methods, Recommendations
Eroglu (2013) Key points:

Comparison of efficacy of  Comparison of efficacy of dry needling, lidocaine injection, and oral flurbioprofen treatments
types of trigger point in patients with myofascial pain.
injections for myofascial  Double-blind (for injection, groups only), randomized clinical trial.
pain  Lidocaine trigger point injection patients had pain reductions of 34 to 88 percent.
 Dry needle patients had similar pain reduction of 31 to 87 percent.
 Patients in each group had similar increases in range of motion after four weeks.
Scott (2009) Key points:
 Systematic review of 15 RCTs.
Trigger point injections for  Head, neck, shoulder, and back pain accounted for 10 RCTs (n = 439).
chronic non-malignant  Only patients with pain persisting for over three months prior to injections included.
musculoskeletal pain  Authors concluded that trigger point injection was safe, but no clear evidence of benefit or
ineffectiveness found — no different from a decade earlier.
Staal (2008) Key points:
 Cochrane review of 18 RCTs, n = 1179.
Injections for subacute  Ten of 18 RCTs taken from 2000 Cochrane review on injections for low back pain.
and chronic low back pain  Eight placebo controlled, 10 compared injections with other therapy.
 Two studies found similar self-reported improvements in pain for trigger point injection with
corticosteroids compared to placebo (dry needle).

References

Professional society guidelines/other:

American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of
Regional Anesthesia and Pain Medicine (ASA/ASRTPM). Practice guidelines for chronic pain
management: An updated report by the American Society of Anesthesiologists Task Force on Chronic
Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology.
2010;112(4):810 — 33.

Chou R, Qaseem A, Snow V, et al. Clinical Efficacy Assessment Subcommittee of the American College of
Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.
Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College
of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478 — 91.

Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a
review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila).
2009;34(10):1078 — 93.

Hayes, Inc. Trigger Point Injections for Myofascial Pain. Lansdale PA: Hayes, Inc. December 24, 2013,
updated December 19, 2017. Accessed December 22, 2017.

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Hooten WM, Timming R, Belgrade M, et al. Institute for Clinical Systems Improvement (ICSI). Assessment
and Management of Chronic Pain. Revised 2013.
https://pdfs.semanticscholar.org/dd36/7a322be4530e818cab86f03ed8b4c7e112a9.pdf. . Accessed
January 13, 2017.

Resnick DK, Choudhri TF, Dailey AT, et al. Guidelines for the performance of fusion procedures for
degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion.
J Neurosurg Spine. 2005;2(6):707 — 15.

Watters WC, Resnick DK, Eck JC. Guideline update for the performance of fusion procedures for
degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion.
J Neurosurg Spine. 2014;21(1):79 — 90.

Peer-reviewed references:

Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized
controlled trial. Clin Rheumatol. 2010;29(1):19 — 23.

Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys,
2002. Spine (Phila). 2006;31(23):2724 — 27.

Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with
implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252 — 65.

Eroglu PK, Yilmaz O, Bodur, Ates C. A comparison of the efficacy of dry needling, lidocaine injection, and
oral flurbioprofen treatments in patients with myofascial pain syndrome: a double-blind (for injection,
groups only), randomized clinical trial. Arch Rheumatol. 2013;28(1):38 — 46.

Gazi MC, Issy AM, Avila IP, Sakata RK. Comparison of acupuncture to injection for myofascial trigger
point pain. Pain Pract. 2011;11(2):132 — 38.

Gobel H, Heinze A, Reichel G, Hefter H, Benecke R. Efficacy and safety of a single botulinum type A toxin
complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a
randomized double-blind placebo-controlled multicenter study. Pain. 2006;125(1-2):82 — 88.

Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review.
Eur J Pain. 2007;11(5):519 — 27.

Malanga GA, Cruz Colon EJ. Myofascial low back pain: A review. Phys Med Rehabil Clin N Am. 2010; 21
(4):711 — 24.

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Manchikanti L, Singh V, Kloth D, et al. Interventional techniques in the management of chronic pain: Part
2.0. Pain Physician. 2001;4(1):24 — 96.

Ozkan F, Cakir Ozkan N, Erkorkmaz U. Trigger point injection therapy in the management of myofascial
temporomandibular pain. Agri. 2011;23(3):119 — 125.

Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology
(Oxford). 2015;54(3):392 – 99.

Saeidian SR, Pipelzadeh MR, Rasras S, Zeinali M. Effect of trigger point injection on lumbosacral
radiculopathy source. Anesth Pain Med. 2014 Sep 8;4(4):e15500.

Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant
musculoskeletal pain: a systematic review. Pain Med. 2009;10(1):54 — 69.

Shen FH, Samartzis D, Andersson GB. Nonsurgical management of acute and chronic low back pain.
J Am Acad Orthop Surg. 2006;14(8):477 — 87.

Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic
low-back pain. Cochrane Database Syst Rev. 2008. Doi: 10.1002/14651858.CD001824.pub3.

Zaralidou AT, Amaniti EN, Maidatsi PG, Gorgias NK, Vasilakos DF. Comparison between newer local
anesthetics for myofascial pain syndrome management. Methods Find Exp Clin Pharmacol.
2007;29(5):353 — 57.

CMS National Coverage Determinations (NCDs):

No NCDs identified as of the writing of this policy.

Local Coverage Determinations (LCDs):

L34211 Trigger Point Injections: Noridian Healthcare Solutions: LLC. Effective October 1, 2015.
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=34211&ver=15&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=Trigger+Point+Injections&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA
AAAAA%3d%3d&. Accessed December 22, 2017.

L34299 Surgery: Trigger Point Injections: Cahaba Government Benefit Administrators ® LLC. Effective
October 1, 2015. https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=34299&ver=10&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=Trigger+Point+Injections&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA
AAAAA%3d%3d&. Accessed December 22, 2017.

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L34588 Trigger Points: Local Injections: Wisconsin Physicians Service Insurance Corporation. Effective
October 1, 2017. https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=34588&ver=13&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=Trigger+Point+Injections&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA
AAAAA%3d%3d&. Accessed December 22, 2017.

L35010 Trigger Point Injections: Novitas Solutions, Inc. Effective October 1, 2015.
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=35010&ver=11&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&
KeyWord=Trigger+Point+Injections&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA
AAAAA%3d%3d&. Accessed December 22, 2017.

L36859 Trigger Point Injections: Noridian Health Care Solutions LLC. Effective May 26, 2017.
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=36859&ver=8&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&K
eyWord=Trigger+Point+Injections&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAA
AAAA%3d%3d&. Accessed December 22, 2017.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.

CPT Code Description Comments

20552 Injection(s); single multiple trigger point(s), one or two muscle(s)
20553 Injection(s); single multiple trigger point(s), three or more muscle(s)

ICD-10 Code Description Comments

M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M53.0 Cervicocranial syndrome
M53.1 Cervicobrachial syndrome
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.2 Cervicalgia
M54.30 Sciatica, unspecified side
M54.31 Sciatica, right side
M54.32 Sciatica, left side
M54.40 Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side

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ICD-10 Code Description Comments
M54.42 Lumbago with sciatica, left side
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified

HCPCS
Description Comments
Level II Code
J1020 Injection, methylprednisolone acetate, 20 mg
J1030 Injection, methylprednisolone acetate, 40 mg
J1040 Injection, methylprednisolone acetate, 80 mg
Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or
G0260
other therapeutic agent, with or without arthrography

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