Are trigger point injections of the left mid posterior lateral chest wall muscles using DepoMedrol (methylprednisolone) and Marcaine (bupivacaine) medically necessary for a patient with myositis and myofascial pain syndrome?

Medical Necessity Determination for Trigger Point Injections

Based on the most recent high-quality guideline evidence, these trigger point injections do NOT meet medical necessity criteria because the patient has not documented failure of conservative treatment for at least 3 months, and the injections are not being provided as part of a comprehensive pain management program including physical therapy. 1

Critical Missing Documentation

The case fails to meet established criteria on multiple fronts:

• No documented conservative treatment failure: The clinical documentation states "pain and functional impairment not responding to conservative measures" but provides no specific details about what conservative treatments were attempted, for how long, or why they failed. 1, 2, 3

• Symptom duration not documented: The criteria require symptoms persisting for more than 3 months, but the documentation does not specify when symptoms began or how long they have been present. 1

• No comprehensive pain management program: The operative report mentions physical therapy only as a post-procedure recommendation ("patient is to enter physical therapy as soon as possible"), not as a concurrent or prior treatment component. Trigger point injections must be part of a comprehensive program including physical therapy, patient education, psychosocial support, and oral medication—not administered in isolation. 1, 2, 3

Guideline-Based Requirements Not Met

The 2020 British Journal of Sports Medicine systematic review of high-quality clinical practice guidelines explicitly states: "Spinal injections (eg, facet joint injections, medical branch blocks, intradiscal injections, prolotherapy and trigger point injections) should not be used for low back pain." 1 While this patient has chest wall myositis rather than low back pain, the same evidence-based principles apply to trigger point injections across anatomical regions.

The internal policy criteria (CPB 0016) requires ALL of the following, which are not met:

1. Conservative treatment failure: Must document specific failed treatments including bed rest, exercises, heating/cooling modalities, massage, NSAIDs, muscle relaxants, and non-narcotic analgesics. 1

2. Three-month symptom duration: Not documented in this case. 1

3. Identified trigger points by palpation: This criterion IS met—8 trigger points were identified at T5-T8 levels. 1

4. Part of comprehensive program: Physical therapy must be concurrent, not just planned for after the procedure. 1, 2, 3

Medication Coverage Issues

The HCPCS codes J0665 (bupivacaine) and J1010 (methylprednisolone acetate) are explicitly listed as "not covered" in the internal policy. 1 This represents a separate denial reason independent of the medical necessity determination for the procedure itself.

Evidence Quality Considerations

The 2005 Journal of Neurosurgery guideline found that trigger point injections with anesthetic provided more pain relief than saline control, but the evidence quality was limited (Class III). 1 More importantly, one study in this guideline showed that dry needling was as effective as drug injection (63% vs 42% improvement, p=0.09), suggesting the mechanical effect rather than the medication may be responsible for any benefit. 1

The most recent evidence from 2023 American Family Physician states: "No single pharmacologic agent used in trigger point injections has been proven superior to another, nor has any single agent been proven superior to placebo." 4 This reinforces that trigger point injections should be reserved only for patients whose myofascial pain has been refractory to other measures. 4

Diagnosis Code Concerns

The diagnosis codes provided (M60.88 - Other myositis, other site; E11.9 - Type 2 diabetes without complications) are not specifically listed in the clinical policy bulletin as covered indications. 1 The diabetes code appears unrelated to the indication for trigger point injections and should not be used to justify this procedure.

Recommended Clinical Pathway

If this patient is to receive trigger point injections in the future, the following must be documented:

• Specific conservative treatments tried and failed: Document at least 3 months of NSAIDs, muscle relaxants, physical therapy with specific exercises, heat/cold therapy, and massage. 1, 2, 3

• Concurrent comprehensive program: Establish physical therapy program BEFORE injections, not after. 1, 2, 3

• Symptom chronology: Document exact onset date and duration of symptoms exceeding 3 months. 1

• Functional impact: Quantifiable pain scores and functional limitations documented at baseline. 2, 3

• Treatment frequency limits: No more than 4 sets of injections total, with at least 7 days between sets, and no more frequently than every 2 months once therapeutic effect achieved. 1, 3

Common Pitfalls in This Case

Performing injections without adequate conservative treatment trial is the primary error. 1, 4 The statement that conservative measures failed is insufficient without documentation of what was tried, when, and for how long.

Planning physical therapy after the procedure rather than as a prerequisite represents a fundamental misunderstanding of evidence-based trigger point injection protocols. 1, 2, 3 The injections are meant to facilitate physical therapy, not replace it.

Using medications (J0665, J1010) that are explicitly non-covered adds an additional denial reason. 1 If trigger point injections were otherwise appropriate, only CPT 20552 would be covered, potentially with normal saline or dry needling. 1, 4