Diagnosis: Myofascial Pain Syndrome.
Treatment: Outpatient procedure code 20553 x 3, trigger point injections.

The insurer denied coverage for Outpatient procedure code 20553 x 3, trigger point injections. The denial is upheld.

This is a patient with no documented history. She is requesting outpatient procedure code 20553 x3, trigger point injections.

Official Disability Guidelines (ODG) Trigger Point Injection (TPI) Criteria for the use of TPIs:

TPI is considered an adjunct, not a primary treatment. Ultrasound guidance for trigger point localization is not recommended. TPIs with any substance (eg, saline, corticosteroid, glucose, Botulinum Toxin) other than local anesthetic are not recommended.

TPI with local anesthetic may be indicated for the treatment of myofascial pain syndrome when all of the following criteria are met: 1) Documentation of circumscribed trigger point(s) with palpation producing a twitch response as well as referred pain, 2) Symptoms have persisted > 3 months, 3) Medical management such as stretching exercises, physical therapy, NSAIDs (non-steroidal anti-inflammatory drug) or muscle relaxants have failed to control symptoms, 4) Radiculopathy is not present by exam, imaging, or neuro-testing, 5) No more than 3-4 injections per session, 6) No repeat injections unless > 50% (percent) pain relief with reduced medication use for at least 6 weeks after injection AND documented evidence of functional improvement, 7) Frequency should not be at an interval < 2 months, 8) There should be documentation of continued ongoing conservative treatment including home exercise and stretching, since use as a sole treatment is not recommended, and 9) If pain persists or recurs after 2-3 injections the treatment plan should be reexamined and may indicate an inappropriate diagnosis.

Contraindications: Acute muscle trauma; Allergies to anesthetic agents; Bleeding disorders; Local or systemic infection; Anticoagulant use.

The scientific literature has recommended injection of anesthetic or corticosteroid for localized areas of pain or spasm. There should be documentation including a full history of the pain mechanism, localization and response to prior treatment. There should be a documented site of pathology and diagnosis. The records provided state: request for outpatient trigger point injections. No other information was provided. Based upon the above, there would be no indication for injections at this time.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the outpatient procedure code 20553 x3, trigger point injections are not substantiated. The insurer's denial is upheld.