Are trigger point injections (CPT code 20553) and nerve blocks (CPT codes 64400, 64405, 64450) medically indicated for the treatment of myofascial pain syndrome, cervicalgia, and occipital neuralgia?

Medical Necessity Determination

Trigger point injections (CPT 20553) for bilateral trapezius and masseter muscles meet medical necessity criteria, but the requested nerve blocks (CPT 64400,64405,64450) for supraorbital, supratrochlear, greater occipital, and lesser occipital nerves do NOT meet medical necessity due to insufficient evidence and failure to meet conservative treatment requirements.

Trigger Point Injections (CPT 20553) - APPROVED with Conditions

Documentation Supports Medical Necessity

• Trigger points have been clearly identified by palpation in the upper trapezius, levator scapulae, rhomboids, and subscapularis muscles 1
• The injections are proposed as part of a comprehensive pain management program including physical therapy referral, pain management referral, and neurosurgery consultation 1, 2
• The patient has documented myofascial trigger points with tenderness on examination 1

Critical Gaps in Documentation

The following criteria are UNSURE or NOT CLEARLY DOCUMENTED and must be clarified:

• Conservative treatment failure is not adequately documented - there is no clear documentation of trials of NSAIDs, muscle relaxants, heating/cooling modalities, or massage therapy with documented failure 1, 3
• Duration of symptoms is unclear - while the patient reports "a couple months of muscle pain," this does not clearly establish the required 3+ months of persistent symptoms 1, 4
• The injections should be limited to a maximum of 4 sets to assess therapeutic response, with no more frequent administration than every 7 days 1

Evidence Supporting Trigger Point Injections

The American Society of Anesthesiologists supports trigger point injections only when used as part of multimodal treatment and after conservative measures have failed 1. Studies demonstrate that trigger point injections with local anesthetics provide significant short-term pain relief (VAS reduction from 8.57 to 2.67 immediately post-injection) 5. However, the effects are mainly observed in the short-term with moderate-to-small effect sizes 6.

Nerve Blocks (CPT 64400,64405,64450) - NOT APPROVED

Supraorbital and Supratrochlear Nerve Blocks (CPT 64400)

These procedures are explicitly listed as having INSUFFICIENT EVIDENCE:

• The American Society of Anesthesiologists states that peripheral nerve blocks for headache/neuralgia have insufficient evidence 1, 7
• Aetna CPB 0863 specifically lists facial nerve blocks for treatment of headache/neuralgia as having insufficient evidence 7
• Multiple guidelines indicate lack of standardization in techniques, types, and doses of local anesthetics used 7

Greater and Lesser Occipital Nerve Blocks (CPT 64405,64450)

These procedures are explicitly listed as having INSUFFICIENT EVIDENCE:

• Aetna CPB 0863 explicitly lists occipital nerve blocks for occipital neuralgia as having insufficient evidence 1
• The American Society of Anesthesiologists states that peripheral somatic nerve blocks should NOT be used for long-term treatment of chronic pain 1, 7
• While some evidence suggests occipital nerve blocks may provide short-term relief, performing multiple interventions simultaneously prevents determination of which procedure provides benefit 2

Additional Concerns for All Nerve Blocks

• Conservative treatment has not been adequately documented - there is no clear evidence of failed trials with NSAIDs, muscle relaxants, topical treatments (lidocaine or diclofenac patches), or adequate physical therapy 1
• The patient is scheduled to see rheumatology - diagnostic workup should be completed before proceeding with interventional procedures 1
• EMG/NCS showed no problems - this suggests the pain may not have a clear neuropathic component that would respond to nerve blocks 7

Clinical Pathway Recommendation

Immediate Steps Required BEFORE Approval

1. Document conservative treatment trials including specific NSAIDs with dosing and duration, muscle relaxants, topical analgesics, and physical therapy with manual therapy techniques 1, 3
2. Clarify symptom duration - must be at least 3 months for trigger point injections 1, 4
3. Complete rheumatology evaluation to rule out systemic inflammatory conditions 1
4. Ensure concurrent physical therapy focusing on stretching, strengthening exercises, and myofascial release is implemented 1, 2

If Conservative Treatment Documented as Failed

• Approve trigger point injections (CPT 20553) ONLY for documented trigger points in trapezius and masseter muscles 1, 5
• Limit to maximum 4 sets of injections to assess therapeutic response 1
• Continue concurrent physical therapy as trigger point injections alone are insufficient 1, 6
• Deny nerve blocks (CPT 64400,64405,64450) due to insufficient evidence per Aetna CPB 0863 and American Society of Anesthesiologists guidelines 1, 7

Common Pitfalls to Avoid

• Performing multiple interventions simultaneously prevents determination of which procedure provides benefit and confounds assessment 2
• Overreliance on injections for long-term management when evidence supports only short-term relief 7, 6
• Failing to address biomechanical factors such as poor posture, sleeping position, and ergonomics that contribute to myofascial pain 5
• Proceeding with interventional procedures before completing diagnostic workup including pending rheumatology evaluation 1