Trigger point injections with anesthetic and/or corticosteroid may be considered medically necessary for the treatment of myofascial pain syndrome when all of the following criteria have been met:
There is a regional pain complaint in the expected distribution of referral pain from a trigger point, AND
There is spot tenderness in a palpable taut band in a muscle, AND
There is restricted range of motion, AND
Conservative therapy (eg, physical therapy, active exercises, ultrasound, heating or cooling, massage, activity modification, or pharmacotherapy) for 6 weeks fails or is not feasible, AND
Trigger point injections are provided as a component of a comprehensive therapy program, AND
No more than 4 injections are given in a 12-month period.
Trigger point and tender point injections are considered investigational for all other indications, including the treatment of myofascial pain syndrome not meeting the criteria above, complex regional pain syndrome, abdominal wall pain, and fibromyalgia.
Ultrasound and other imaging guidance of trigger point injections are considered investigational.