CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dry Needling of Trigger Point for Myofascial Pain

Policy governing coverage of dry needling of trigger points for treatment of myofascial pain for Blue Cross Blue Shield - Rhode Island Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDry Needling of Trigger Point for Myofascial Pain

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 21, 2016

Next Review DateN/A

Key ActionVerify member benefits and refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for coverage and financial responsibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not Medically NecessaryCoverage stance for dry needling (Commercial Products)

20560,20561CPT codes listed as not medically necessary

Insufficient evidenceEffect on health outcomes

Coverage Determination and Criteria

Coverage Determination — Not medically necessary

Not medically necessary

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For Blue Cross Blue Shield of Rhode Island Commercial Products, coverage for dry needling procedures is governed by the member’s applicable plan documents. Benefits and coverage may vary by group and contract; providers should refer to the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether the service is covered and to identify any member financial responsibility.

Provider Responsibilities and Billing Guidance

Note

Prior Authorization

Prior authorization is not applicable for this policy.

Note

Benefit Verification and Member Financial Responsibility

Benefits may vary between groups and contracts. Refer to the member's Benefit Booklet/Evidence of Coverage/Subscriber Agreement for specific coverage and member financial responsibility.

Denial Risk

Provider Actions — Claims and Coding Guidance

For Commercial Products, dry needling (CPT codes 20560 and 20561) is considered not medically necessary and may be denied. Needling of trigger points for treatment of myofascial pain is considered not medically necessary due to insufficient evidence of benefit and a high incidence of mild adverse events. For dates of service on or after 1/1/2020, CPT codes 20560 (needle insertion(s) without injection(s); 1 or 2 muscles) and 20561 (needle insertion(s) without injection(s); 3 or more muscles) are not medically necessary. For claims with dates of service prior to 1/1/2020, an unlisted procedure code should be used; dry needling is not acupuncture and CPT codes 97810-97814 are not appropriate.

Affected CPT codes: 20560, 20561
Dry needling is not acupuncture; do not use CPT 97810-97814 for this service

Clinical Background

A trigger point is a discrete, focal, hyperirritable spot within a taut band of skeletal muscle fibers that can produce local and/or referred pain when stimulated. Dry needling is a procedure in which a fine needle is inserted into the skin and muscle at a myofascial trigger point without injection of medication, with the intent of eliciting a local twitch response to inactivate the trigger point and relieve pain. Superficial and deep needling techniques have been proposed to work via different physiologic mechanisms, but the reliability of manual trigger point identification and the clinical superiority of dry needling over sham or manual therapies have not been established.

Key Definitions

Trigger point — definition

DefinitionDiscrete, focal, hyperirritable spot within a taut band of skeletal muscle fibers that produces local and/or referred pain when stimulated.

Associated featuresAssociated with local ischemia, hypoxia, lowered pH, altered muscle activation patterns, and may be visualized by MRI or elastography.

Clinical signMay produce local twitch response (transient visible or palpable muscle contraction or dimpling) when stimulated.

ReliabilityManual identification reliability of trigger points has not been established.

Most actionableTrigger points are focal hyperirritable spots in taut muscle bands that produce local or referred pain when stimulated — identification of these spots is the basis for interventions like dry needling.

Dry needling — definition of procedure

DefinitionProcedure in which a fine needle is inserted into the skin and muscle at a myofascial trigger point without injection of medication, aiming to elicit a local twitch response.

Technique detailsNeedle may be moved up-and-down, rotated, and/or left in place for up to 30 minutes; performed with acupuncture or standard hypodermic needles but without injection of medications.

Intended effectIntended to stimulate trigger points, elicit a local twitch response, inactivate the trigger point, reduce local/referred pain, and improve range of motion.

DistinctionNo medication is injected during the procedure (contrasts with injection-based therapies).

LimitationsPhysiologic mechanisms differ by depth (superficial vs deep); clinical superiority over sham or manual therapies has not been established.