Does not apply to BlueCare
DESCRIPTION
Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS). Myofascial pain is a common, non-articular musculoskeletal disorder characterized by symptomatic myofascial trigger points - hard, palpable, localized nodules within taut bands of skeletal muscle that are painful upon compression. MPS is a chronic condition affecting the connective tissue (i.e., fascia) surrounding the muscles; sensitive points in your muscles (trigger points) cause referred pain in seemingly unrelated parts of the body. MPS typically occurs after a muscle has been contracted repetitively. The large upper back muscles are prone to developing myofascial pain, as well as the neck, shoulders, heel and temporomandibular joint. Pain that persists for extended periods of time (generally greater than 3 months) and fails to be alleviated with conservative approaches may be treated with injections of local anesthetics, anti-inflammatory drugs, and/or corticosteroid in an attempt to deactivate the trigger point.
Dry needling is a variant of trigger point injection and refers to a procedure in which a fine needle is inserted into the skin and muscle at the 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; no medications are given through the needle. Dry needling is not the same as acupuncture.
POLICY
Trigger point injections with local anesthetics, with or without steroids, are considered medically necessary. (Note: No more than four (4) trigger point injection sessions are considered appropriate in a one-year period.)
Ultrasound guidance of trigger point injections is considered not medically necessary.
Dry needling for the treatment of trigger points is considered investigational.
Any device or agent utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
Does not apply to BlueCare
ADDITIONAL INFORMATION
There are limited comparative studies available in peer-reviewed journals to determine efficacy or utility of dry needling in the treatment of trigger points. Palpation remains the standard of care for the diagnosis of trigger points and the technique utilized in the guidance of the injections.
SOURCES
Ahmed, S., Subramaniam, S., Sidhu, K., Khattab, S., Singh, D., Babineau, J., & Kumbhare, D.A. (2019). Effect of local anesthetic versus botulinum toxin-A injections for myofascial pain disorders: a systematic review and meta-analysis. The Clinical Journal of Pain, 35 (4), 353-367. Abstract retrieved January 3, 2020 from PubMed database.
Aksu, Ö., Doğan, Y.P., Ҫağler, N.S., Şener, B.M. (2019). Comparison of the efficacy of dry needling and trigger point injections with exercise in temporomandibular myofascial pain treatment. Turkish Journal of Physical Medicine and Rehabilitation, 65 (3), 228-235. (Level 2 evidence)
BlueCross BlueShield Association. Evidence Positioning System. (5:2023). Dry needling of trigger point for myofascial pain (2.01.100) Retrieved October 9, 2023 from https://www.bcbsaoca.com/eps/. (16 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (5:2023). Trigger point and tender point injections (2.01.103). Retrieved October 9, 2023 from https://www.bcbsaoca.com/eps/. (16 articles and/or guidelines reviewed)
Boyles, R., Fowler, R., Ramsey, D., & Burrows, E. (2015). Effectiveness of trigger point dry needling for multiple body regions: a systematic review. Journal of Manual and Manipulative Therapy, 23 (5), 276-293. (Level 2 evidence)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2020, November). LCD for Trigger point injections (LCD ID: L37635). Retrieved August 4, 2021 from https://www.cms.gov.
Dessie, S.G., Von Bargen, E., Hacker, M.R., Haviland, M.J., & Elkadry, E. (2019). A randomized, double-blind, placebo-controlled trial of onabotulinumtoxin A trigger point injections for myofascial pelvic pain. American Journal of Obstetrics and Gynecology, 221 (5), 517. Abstract retrieved November 18, 2020 from PubMed database.
Liu, L., Huang, Q.M., Lie, Q.G., Ye, G., Bo, C.Z., Chen, M.J., et al. (2015). Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systemic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 96 (5), 944-955. Abstract retrieved July 2, 2015 from PubMed database.
Winifred S. Hayes, Inc. Medical Technology Directory. (2023, June). Dry needling for knee osteoarthritis in adults. Retrieved October 9, 2023 from www.Hayesinc.com/subscribers. (27 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2023, May). Dry needling for mechanical neck and/or trapezius muscle pain in adults. Retrieved October 9, 2023 from www.Hayesinc.com/subscribers. (22 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 7/14/2012
MOST RECENT REVIEW DATE: 12/14/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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