Trigger Point Injections for Pain Management (PDF)
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Defines medical necessity criteria, limitations, excluded indications, and coding guidance for trigger point injections (local anesthetic with/without steroid) performed by physicians for myofascial pain management.
Policy split from CP.MP.118; minor rewording for clarity and background updates over successive annual reviews.
Replaced 'not medically necessary' language with 'current evidence does not support' for certain therapies.
Coverage Summary
Policy CP.MP.169: Trigger Point Injections for Pain Management — SUBJECT: Trigger Point Injections for Pain Management; STATUS: CURRENT. This policy defines medical necessity criteria and limits for physician‑performed trigger point injections (local anesthetic with or without steroid) for myofascial pain and is classified as covered with criteria.
Key thresholds and limits (summary):
- Duration of myofascial pain prior to initial injections: > 3 months (required).
- Minimum conservative therapy before initial treatment: ≥ 3 weeks of conventional multidisciplinary therapy.
- Diagnostic/stabilization repeats: Up to two sets of injections at least 7 days apart for the same trigger point.
- Additional injections: Given at least 2 months apart, for up to 12 months from the initial injection, with a maximum of 6 total sessions when criteria are met.
Medical-Necessity Criteria
I. Initial diagnostic/stabilization trigger point injections (medically necessary)
Covered when ALL of the following are met:
ALL of the following
Failed conservative multidisciplinary therapy
- Therapy components: Chiropractic, physical therapy, or prescribed home exercise program OR patient is unable to tolerate such therapy and the injection is intended as a bridge to therapy
- Medication: NSAID, unless contraindicated or not tolerated
- Activity modification
- Duration of myofascial pain: The member/enrollee has myofascial pain that has persisted for more than three months causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed> 3 months
- Trigger point identification: Trigger points have been identified by palpation
- Focal vs widespread: Trigger points are located in a few discrete areas and are not associated with widespread areas of muscle tenderness (as with fibromyalgia)
- Adjunctive use: Injections are not used as sole method of treatment but intended to facilitate mobilization to allow non-invasive modalities (e.g., physical therapy) that address muscle strengthening, flexibility, and functional restoration
- One procedure per visit: Only one procedure per visit is performed
- Diagnostic/stabilization repeat interval: Up to two sets of injections at least seven days apart may be given for diagnosis and stabilization for the same trigger pointUp to two sets, at least 7 days apart
- Body region aggregation: When a given body region is injected, it is considered one injection service regardless of number of injections given
II. Additional trigger point injections (up to four additional sessions) — medically necessary when criteria met
Covered when ALL of the following are met:
ALL of the following
- Prior response: Prior injections resulted in ≥ 50% pain relief with functional improvement for ≥ 6 weeks≥ 50% relief with functional improvement for ≥ 6 weeks
- Recurrence after improvement: There was a return of pain and/or deterioration following ≥ 6 weeks of improvement≥ 6 weeks
- Interval and total sessions: Injections are given at least two months apart for up to 12 months from the initial injection (maximum of six total sessions)At least 2 months apart; up to 12 months from initial injection; maximum of 6 sessions
Up to four additional sessions after initial course
- Adjunctive use: Injections are not used as sole method of treatment but intended to facilitate mobilization to allow non-invasive modalities (e.g., physical therapy) that address muscle strengthening, flexibility, and functional restoration
- Body region aggregation: When a given body region is injected, it is considered one injection service regardless of number of injections given
III. Indications not supported by current evidence (not supported)
Current evidence does not support the use of trigger point therapies for the following:
Not supported by current evidence
- Dry needling: Dry needle stimulation of trigger points
- Saline or glucose: Trigger point injection with saline or glucose
- Botox: The use of Botox (botulinum toxin) during trigger point injections
Coding Guidance
Provider Actions & Billing Rules
Document prior conservative therapy and response
Document that the member failed ≥ 3 weeks of conventional multidisciplinary therapy (chiropractic, physical therapy, or a prescribed home exercise program — or document inability to tolerate such therapy), completed an NSAID trial unless contraindicated or not tolerated, and attempted activity modification for initial injections. For additional injections, document prior injections resulted in ≥ 50% pain relief with functional improvement lasting ≥ 6 weeks and that pain returned or deteriorated after that period.
- Initial injections: failure of ≥ 3 weeks of multidisciplinary therapy (chiropractic/physical therapy/home exercise or inability to tolerate)
- Initial injections: NSAID trial unless contraindicated or not tolerated
- Initial injections: activity modification attempted
- Additional injections: prior result ≥ 50% pain relief with functional improvement for ≥ 6 weeks and subsequent return/worsening of pain
Background & Evidence Summary
Background: Trigger points are hyperirritable foci within palpable taut bands in skeletal muscle that cause local and referred pain. Trigger point injections of local anesthetic and/or steroids are commonly used for back and neck pain but the published evidence is mixed; Cochrane and guideline reviews report no clear advantage or insufficient evidence for routine benefit.
Clinical context: Trigger point injections are frequently used as a tool for diagnosis/stabilization or to facilitate rehabilitation, but systematic reviews and guideline assessments note limited or inconclusive benefit for short‑term pain relief in subacute/chronic back and neck pain.
Evidence on alternatives: Dry needling has preliminary evidence for short‑term benefit but requires higher‑quality standardized studies; botulinum toxin (Botox) injections have not demonstrated confirmed clinically significant benefit for chronic neck pain. The policy therefore states that dry needling, saline/glucose injections, and Botox use during trigger point injections are not supported by current evidence.
| Source | Conclusion |
|---|---|
| Cochrane/Systematic review | |
| No clear advantage of local/trigger point injections for short-term pain relief in subacute/chronic back pain | |
| NASS conclusion | |
| Insufficient evidence to recommend for or against trigger point injections for low back pain | |
| Dry needling evidence | |
| Preliminary evidence for short-term pain relief and improved quality of life and range of motion versus placebo; further high-quality standardized studies needed | |
| Botulinum toxin evidence | |
| Systematic reviews do not confirm a statistically or clinically significant benefit of botulinum toxin-A for chronic neck pain in the short term |
Trigger point injection: Injection of a local anesthetic, with or without steroid medication, into a painful portion of the muscle containing the trigger point.
Myofascial pain: Pain originating in muscles characterized by focal tenderness, restricted motion, and referred pain with compression.
Medicare Local Coverage Determinations
| Name | Number | Type | Effective / Revised Date |
|---|---|---|---|
| Trigger point injections (TPI) | |||
| L36859 | |||
| LCD | |||
| Published 2017-05-26 (revised 2024-04-01) | |||
| Trigger point injections | |||
| L39713 | |||
| LCD | |||
| Effective 2024-04-01 | |||
| Billing and coding: pain management - injection tendon sheath, ligament, ganglion cyst, carpal and tarsal tunnel | |||
| A52863 | |||
| LCA | |||
| Published 2015-10-10 (revised 2024-10-01) |
Revision History
Policy split from CP.MP.118; minor rewording for clarity and background updates.
CPT 20560 and 20561 added as codes that do not support coverage criteria.
Changed maximum of 6 injections/year to 4; added ICD-10 code M79.18 and changed M79.1 to M79.12; references reviewed and updated.
Annual review; replaced 'not medically necessary' language with 'current evidence does not support' in criteria II; header wording changes and terminology updates.
Updated criteria II to replace prior limits with explicit pain relief and timing requirements (added pain relief with functional improvement and ≥ 6 weeks), changed number of additional injections and timing language.
Annual review; removed 'with or without radiographic guidance' language and updated 'myofascial pain' wording in criteria; background updated.
Annual review; references reviewed and updated. Date of last revision recorded as 07/25.
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