Trigger Point Injections TRIGGER POINT INJECTIONS HS-184. Policy Number: HS-184. Original Effective Date: 7/1/2010

Transcription

1 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan Windsor Rx Medicare Prescription Drug Plan Trigger Point Injections Policy Number: Original Effective Date: 7/1/2010 Revised Date(s): 8/2/2011; 6/7/2012; 8/9/2013; 8/7/2014; 7/9/2015 APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

2 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult for list of current LOBs. BACKGROUND Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Members may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms. There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis 1 : History of onset and its cause (injury, sprain, etc.); Distribution of pain; Restriction of movement; Mild muscle specific weakness; Focal tenderness of a trigger point; Palpable taut band of muscle in which trigger point is located; Local taut response to snapping palpitation; and Reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point. NOTE: For all conditions, the actual area must be reported specifically and must be documented in the medical record. Myofascial Pain Myofascial trigger points are "small, circumscribed, hyperirritable foci in muscles and fascia, often found with a firm or taut band of skeletal muscle." (See Item 2 under "Sources of Information and Basis for Decision.") These trigger points produce a referred pain patterned characteristic for that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with every perpetuating factor. The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain. There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon the detailed history and thorough examination. 2,3 The goal is to identify and treat the cause of the pain, not just the symptom. Upon diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are: Clinical Coverage Guideline page 2

3 1. Medical management, which may include consultation with a specialist in pain medicine 2. Medical management that may include the use of analgesics and adjunctive medications, including antidepressant medications, shown to be effective in the management of chronic pain conditions. 3. Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of motion and deep muscle massage. 4. Active physical therapy, including active range of motion, exercise therapy and physical conditioning. Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible). 5. Manipulation therapy. 6. Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points. POSITION STATEMENT 2,4,5 Applicable To: Medicaid Florida, Georgia, Hawaii, Kentucky Medicare California (Easy Choice), Florida, Georgia, Hawaii NOTE: The following markets utilize vendor criteria set forth by Care Core National. Medicare - Connecticut, Illinois, Kentucky, Louisiana, New Jersey, New York, Ohio, Texas, and Windsor. Medicaid - Illinois, Missouri, New Jersey, New York, South Carolina Trigger point injections are considered medically necessary and a covered benefit when illness or injury have occurred and cause tenderness and/or weakness, restricting motion and/or causing referred pain when compressed 2. Use of injections should be done as part of an overall management (usually short term) plan including one or more of the following: Diagnostic evaluation to clearly identify the primary cause, if possible. Physical and occupational therapy. Psychiatric evaluation and therapy. A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated. 1. To establish a diagnosis, the following criteria must be met: Member must have a regional pain complaint; AND, Pain complaint or altered sensation in expected distribution of referred pain is from a trigger point; AND, Taut band palpable is in accessible muscle with exquisite tenderness at one point along length of it; AND, Some degree of restricted range of motion present, when measurable. 2. In addition, one of the following is also needed for diagnosis: Reproduction of referred pain pattern by stimulating the trigger point; OR, Altered sensation by pressure on the tender spot; OR, Local response elicited by snapping palpation at tender spot or by needle insertion into tender spot; OR, Pain alleviated by stretching or injecting the tender spot. TRIGGER POINT INJECTION SCHEDULE The following schedule for trigger point injections is considered medically necessary when the above criteria are met: In the diagnostic or stabilization phase, patients may receive injections at intervals of no sooner than one week and preferably two weeks. The number of trigger point injections should be limited to no more than four times per year for the diagnostic or stabilization phase. Clinical Coverage Guideline page 3

4 In the treatment or therapeutic phase, trigger point injections should continue only if the previous diagnostic injections provided pain relief and the frequency should be two months or longer between each injection. The previous injections should have provided at least >50% relief of pain for a period of at least six weeks. The injections should be repeated only as necessary based on the medical necessity criteria (see above) and these should be limited to maximum of six times for local anesthetic and steroid injections Under unusual circumstances such as a recurrent injury or cervicogenic headache, trigger point injections may be repeated at intervals of six weeks after stabilization in the treatment phase. American Society of Anesthesiologists & American Society of Regional Anesthesia (2010) support Trigger Point Injections: Recommendations for trigger point injections. Trigger point injections may be considered for treatment of patients with myofascial pain as part of a multimodal approach to pain management. TRIGGER POINT FOR MYOFASCIAL PAIN 2 Trigger point injections with a local anesthetic with or without steroid are considered medically necessary for the treatment of myofascial pain when ALL of the following criteria from Set A AND B are met: SET A (General Criteria) There is a regional pain complaint; AND, A neurological/orthopedic/musculoskeletal system evaluation which includes the member's description of pain as it relates to location, quality, severity, duration/timing, context, and modifying factors, followed by a physical examination of associated signs and symptoms; AND, Conservative therapy (e.g., physical/chiropractic therapy, oral analgesia/steroids/relaxants, activity modification) fails or is not feasible; AND, When necessary to facilitate mobilization and return to activities of daily living, an aggressive regimen of physical therapy or other therapeutic modalities; AND, The member's response to therapy must be documented for medical review prior to additional therapy authorizations. SET B (Specific Criteria) Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point; AND, Taut band palpable in an accessible muscle when the trigger point is myofascial; AND, Exquisite spot tenderness at one point along the length of the taut band when the pain is myofascial; AND, Some degree of restricted range of motion of the involved muscle or joint, when measurable; AND, The above specific criteria are associated with at least ONE of the following: o Reproduction of clinical pain complaint or altered sensation by pressure on the tender spot; OR, o Local response (twitch) elicited by snapping palpation at the tender spot or by needle insertion into the tender spot; OR, o Pain alleviation by elongating (stretching) the muscle or by injecting the tender spot. TRIGGER POINT FOR FIBROMYALGIA Trigger point injections with a local anesthetic with or without steroid are considered medically necessary for the treatment of pain associated with fibromyalgia when: History of widespread pain for at least 3 months. To be considered wide spread, the pain must be present on both right and left sides, and both above and below the waist. In addition axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back pain" is considered lower segment Clinical Coverage Guideline page 4

5 pain; AND, Pain, on digital palpation, must be present in at least 11 of the following 18 sites: o Occiput: Bilateral, at the suboccipital muscle insertions; o Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7; o Trapezius: bilateral, at the midpoint of the upper border; o Supraspinatus: bilateral, at origins, above the scapula spine near the medial border; o Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces; o Lateral epicondyle: bilateral, 2 cm distal to the epicondyles; o Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle; o Greater trochanter: bilateral, posterior to the trochanteric prominence; o Knee: bilateral, at the medial fat pad proximal to the joint line. NOT MEDICALLY NECESSARY Trigger point injections are considered not medically necessary in the presence of: Systemic infections; OR, Bleeding tendencies; (including patients undergoing anticoagulation therapy); OR, Other concomitant unstable medical conditions. In addition, "dry needling" trigger point stimulation is considered not medically necessary 6. CODING Covered CPT * Codes Injection(s); single or multiple trigger point(s), one or two muscle(s) Injection(s); single or multiple trigger point(s), three or more muscle(s) Unspecified therapeutic procedure; i.e. dry needling trigger points HCPCS *Code - No applicable code Covered ICD-9-CM Procedure Codes Injection of locally-acting therapeutic substance into other soft tissue Covered Draft ICD-10-PCS Codes 3E023BZ Administration, Physiological Systems/Anatomical Regions, Introduction, Muscle, percutaneous, local anesthetic Covered ICD-9-CM Diagnosis Code This list may not be all inclusive Cervicalgia Unspecified Musculoskeletal Disorders and Symptoms Referable to Neck Pain in thoracic spine Lumbago Other specified disorders of bursae and tendons in Shoulder Region Myalgia and Myositis Unspecified (Fibromyalgia) Covered DRAFT ICD-10-CM Diagnosis Codes M54.2 Cervicalgia M53.82 Unspecified Musculoskeletal disorders and symptoms referable to neck M54.5 Low back pain M54.6 Pain in thoracic spine M75.80 Other specified disorders of bursae and tendons in shoulder region Clinical Coverage Guideline page 5

6 M75.81 Other shoulder lesions, right shoulder M75.82 Other shoulder lesions, left shoulder M60.80 M60.9 Other myositis M79.1 Myalgia (myofascial pain syndrome) M79.7 Fibromyalgia *Current Procedural Terminology (CPT ) 2015 American Medical Association: Chicago, IL. REFERENCES 1. Local coverage determination: trigger point injections (L28310). Centers for Medicare and Medicaid Services Web site. Published Accessed July 1, Local coverage determination: trigger points, local injections (L30155). Centers for Medicare and Medicaid Services Web site. Published Accessed July 1, Trigger point injections for myofascial pain. Hayes Directory Web site. Published December 5, 2012 [reviewed December 10, Accessed July 1, American Society of Anesthesiologists, and American Society of Regional Anesthesia. Practice guidelines for chronic pain management: an updated report. Anesthesiology. 2010;112(4): Health care guideline: assessment and management of chronic pain. Institute for Clinical Systems Improvement Web site. Published November Accessed July 1, Dry needling for treatment of myofascial pain in adults. Hayes Directory Web site. Published July 23, 2013 [reviewed November 20, 2014]. Accessed July 1, MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 7/9/2015, 8/7/2014 8/9/2013 6/7/ /1/2011 8/2/2011 Approved by MPC. No changes. Reinstated for markets where CareCore is not a vendor. Retired by MPC; covered by CareCore musculoskeletal criteria. New template design approved by MPC. Approved by MPC. No changes. Clinical Coverage Guideline page 6