Medical Necessity Determination for Myofascial Pain Management

Trigger Point Injections

The American Society of Anesthesiologists supports trigger point injections only when used as part of multimodal treatment and after conservative measures have failed 3
Trigger points have been identified by palpation in the trapezius, levator scapulae, rhomboids, and subscapularis muscles 2
The injections are proposed as part of a comprehensive pain management program including PT referral, pain management referral, and neurosurgery consultation 3, 1

The American Society of Anesthesiologists states that peripheral somatic nerve blocks should NOT be used for long-term treatment of chronic pain 3, 4
Supraorbital and supratrochlear nerve blocks (CPT 64400) for headache/neuralgia are listed as having insufficient evidence by the American Society of Anesthesiologists 4
Greater and lesser occipital nerve blocks (CPT 64405, 64450) for occipital neuralgia are explicitly listed as having insufficient evidence in Aetna's CPB 0863 4

NSAIDs with documented trial and response should be attempted before proceeding to injections 1
Muscle relaxants for documented muscle spasm should be attempted before proceeding to injections 1
Physical therapy focusing on manual therapy techniques, myofascial release, stretching, and strengthening exercises should be attempted before proceeding to injections 1, 2
Topical treatments including lidocaine patches or diclofenac patches should be attempted before proceeding to injections 1

The American Society of Anesthesiologists recommends considering trigger point injections (CPT 20553) for documented trigger points in trapezius and masseter muscles after 3+ months of conservative treatment failure 3, 1
Limit to 4 sets of injections maximum to assess therapeutic response 3
Continue concurrent physical therapy as trigger point injections alone are insufficient 3, 1