RETIRED Local Coverage Determination (LCD)

Trigger Point Injections

L37635

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37635
Original ICD-9 LCD ID
Not Applicable
LCD Title
Trigger Point Injections
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 02/26/2018
Revision Effective Date
For services performed on or after 11/26/2020
Revision Ending Date
03/30/2024
Retirement Date
03/30/2024
Notice Period Start Date
12/14/2017
Notice Period End Date
02/25/2018

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1 §30.3 - Acupuncture.

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2 §150.7 - Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications

An active trigger point has pain at rest, has pain on palpitation, has radiation of pain, and has a local twitch response. Trigger point injections are indicated in symptomatic trigger points. The history of onset of the painful condition and its presumed cause, location, duration, failed therapies and recommendations for injection therapy of each clearly delineated muscle must be in the patient’s chart and made available to Medicare upon request. The goal is to treat the cause of the pain and not just the symptom of pain.

Limitations

  1. Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long term benefits. There is no peer-reviewed literature to substantiate more than four trigger point injections in a year.
  2. Prolotherapy is not covered by Medicare. If prolotherapy is billed using trigger point therapy codes it will be considered not reasonable and necessary.
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

The patient’s medical record must have:

  • Documentation of the physical findings leading to diagnosis of the trigger point.

  • The involved muscle group(s) must be documented in the patient’s medical record as well as the number of trigger points injected. A diagram with an "X" or other similar annotation is not adequate documentation.

  • Documentation of the reason(s) for selecting this therapeutic option.

All coverage criteria must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

Sources of Information

N/A

Bibliography

Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002;65(4):653-660.

Borg-Stein J, Stein J. Trigger point and tender points one and the same? Does injection treatment help? Rheumatic Disease Clinics of North America. 1996;22(2):305–322.

Ingber RS. Position Paper on Trigger Point Injections [Fibromyalgia and Myofascial Pain News]; 03-28-2003.

Consultations with the representatives to the Carrier Advisory Committee

Other Medicare Carriers’ LCDs

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/30/2024 R6

This LCD is being retired because the information in this policy has been incorporated within the Trigger Point Injections (TPI) L39671 LCD.

  • LCD Being Retired
11/26/2020 R5

Under Coverage Indications, Limitations and/or Medical Necessity Limitations removed the statement “Acupuncture is not covered by Medicare. If acupuncture is billed using trigger point therapy codes it will be considered not reasonable and necessary.”

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/24/2019 R4

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Trigger Point Injections A56745 article. All verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Trigger Point Injections A56745 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
07/25/2019 R3

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Trigger Point Injections A56745 article.

Under Associated Information deleted the second sentence. Under Bibliography changes were made to citations to reflect AMA citation guidelines.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
09/13/2018 R2

Under Documentation Requirements the following verbiage has been deleted: Diagnosis codes from the “ICD-10-CM Codes that Support Medical Necessity” section must be used to support the specific muscles injected. Generalized diagnoses like low back pain, lumbago, etc. will not be covered.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
  • Public Education/Guidance
02/26/2018 R1

The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.

  • Other
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
03/30/2024 11/26/2020 - 03/30/2024 Retired You are here
11/20/2020 11/26/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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