Is an interlaminar epidural steroid injection (CPT code 62321) and trigger point injection (CPT code 20552) medically necessary for the treatment of intervertebral disc displacement (M51.24) and myalgia (M79.18)?

Medical Necessity Determination for Thoracic Interlaminar Epidural Injection and Trigger Point Injections

Based on the clinical documentation provided, the thoracic interlaminar epidural steroid injection (CPT 62321) at T8-9 meets medical necessity criteria, but the trigger point injections (CPT 20552) do NOT meet medical necessity criteria for chronic low back pain from degenerative disease.

Thoracic Interlaminar Epidural Injection (CPT 62321) - MEDICALLY NECESSARY

Radicular Pain Requirement Met

• The patient demonstrates thoracic radiculopathy with pain radiating in a dermatomal pattern from the thoracic spine, documented as "Pain in Thoracic Spine" and "Thoracic Disc Displacement" with corresponding MRI findings of disc displacement at the thoracic region 1
• The Aetna criteria specify that pain must be radicular in nature with dermatomal sensory loss patterns, which is documented in this case 1

Conservative Treatment Requirement Met

• The patient has failed more than 4 weeks of conservative treatment including physical therapy, previous epidural steroid injections, NSAIDs (ibuprofen), and opioid analgesics (Percocet) 1
• The American College of Physicians requires at least 4 weeks of failed conservative management before epidural injections are considered medically necessary 1

Imaging Requirement Met

• MRI from 8/23/24 (within 24 months) demonstrates objective pathology: disc osteophyte at C6-C7 with foraminal stenosis, ligamentum flavum thickening, and spinal canal stenosis 1
• Advanced diagnostic imaging within 24 months is required by Aetna criteria to rule out intraspinal tumor or other space-occupying lesions 1

Comprehensive Pain Management Program

• The documentation indicates the patient is receiving multimodal treatment including physical therapy, oral medications (NSAIDs, opioids), and interventional procedures 1
• Aetna requires that epidural injections be part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications 1

Critical Caveat for Thoracic Injections

• While most evidence focuses on lumbar epidural injections, the thoracic interlaminar approach is technically appropriate for thoracic disc displacement and thoracic radicular pain 2
• Fluoroscopic guidance was utilized (documented as "Fluoroscopic Localization of Needle Placement"), which is essential for proper needle placement and safety 1

Trigger Point Injections (CPT 20552) - NOT MEDICALLY NECESSARY

Insufficient Evidence for Long-Term Benefit

• The Journal of Neurosurgery provides Grade B recommendation AGAINST trigger point injections for chronic low back pain without radiculopathy because long-lasting benefit has not been demonstrated 3
• TPIs performed as dry needling, with anesthetics alone or with steroids, are not recommended in patients with chronic low-back pain from degenerative disease because sustained benefit beyond 2 weeks has not been proven 3

Evidence Shows Only Short-Term Relief

• Multiple randomized controlled trials demonstrate that TPIs may provide short-term relief (less than 2 weeks) but do not show clinically meaningful long-term improvement 3
• Studies by Hameroff et al. and Sonne et al. showed pain reduction at 7 days and 2 weeks respectively, but no evidence of sustained benefit beyond this timeframe 3
• The Garvey et al. study found that dry needling (63% improvement) was not statistically different from drug injection (42% improvement, p=0.09), suggesting the needle stimulation itself rather than the medication provides the effect 3

Myofascial Pain Diagnosis (M79.18) Does Not Support Medical Necessity

• While the patient has documented "Myofascial Pain (M79.1)" and "Myalgia Other Site (M79.18)," the evidence base for TPIs in this context is Level III medical evidence at best 3
• The studies supporting TPIs were conducted in patients with acute onset low back pain (not chronic), assessed shortly after injection, and showed benefit only in selected patients 3

Lack of Documentation for Comprehensive TPI Protocol

• Effective TPI treatment requires correction of mechanical and systemic perpetuating factors according to Simons and Travell's criteria, which is not clearly documented in this case 3
• The bilateral thoracic paraspinal trigger point injections appear to be administered in isolation rather than as part of a comprehensive myofascial pain management program with ongoing physical therapy specifically targeting trigger points 3

Key Clinical Pitfalls to Avoid

For Epidural Injections

• Do not confuse axial back pain with radicular pain: The patient must have pain radiating in a dermatomal pattern, not just localized spinal pain 1
• Ensure fluoroscopic guidance is documented: This is mandatory for safety and proper medication delivery 1
• Document the comprehensive pain management program: Epidural injections should never be performed in isolation 1

For Trigger Point Injections

• Recognize the limited evidence base: TPIs have only Level III evidence for short-term benefit (less than 2 weeks) in chronic degenerative spine disease 3
• Distinguish acute from chronic presentations: The positive TPI studies were conducted in acute low back pain patients, not chronic degenerative disease 3
• Avoid routine use without comprehensive myofascial treatment: TPIs require identification of specific trigger points by palpation and correction of perpetuating factors 3

Recommendation Summary

The thoracic interlaminar epidural steroid injection (CPT 62321) is medically necessary as all Aetna criteria are met: radicular pain pattern, failed conservative treatment exceeding 4 weeks, recent MRI demonstrating pathology, and provision as part of comprehensive pain management 1.

The trigger point injections (CPT 20552) are NOT medically necessary based on Grade B recommendation from the Journal of Neurosurgery against TPIs for chronic back pain from degenerative disease, with only Level III evidence supporting short-term benefit of less than 2 weeks 3.