CurrentCareSourcePolicy Trigger Point Injections-AR PASSE-MM-1503

Trigger Point Injections

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Defines medical necessity criteria, documentation requirements, limits, and payment rules for trigger point injections (TPIs) for back pain, neck pain, or myofascial pain syndrome for CareSource Arkansas PASSE.

Policy Summary

PayerCareSource

PolicyTrigger Point Injections

Policy CodePolicy Trigger Point Injections-AR PASSE-MM-1503

Change TypeNo material changeinitial issuance and annual reference updates

Effective DateApr 1, 2026

Last ReviewFeb 28, 2024

Next Review Date

Key ActionDocument evaluation with history and physical, reasons for TPI, affected muscles, muscles injected and number, injection frequency, medication name, prior treatment results, and corroborating evidence of medical necessity.

SourceLink

POLICY UPDATE CHANGES

Policy created and issued 05/10/2023 as new policy.

Annual review on 02/28/2024: updated references and approved at Committee.

Effective date set to 04/01/2026.

8Max reimbursed dates of service per year

50%Required documented improvement to repeat injection

1 monthMinimum conservative therapy before TPI

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