Are myofascial trigger point injections, right greater and lesser trochanteric bursa injections, right lateral cutaneous nerve block, and right iliotibial band injections medically necessary for treating hip pain?

Medical Necessity Determination for Requested Hip Pain Procedures

Direct Answer

None of the requested procedures meet medical necessity criteria based on the documentation provided, and the simultaneous request for multiple invasive procedures violates established clinical policy requiring only one invasive modality at a time. 1

Detailed Rationale by Procedure

Right Lateral Cutaneous Nerve Block (CPT 64450)

This procedure is NOT medically necessary because the Aetna policy explicitly states lateral femoral cutaneous nerve blocks are indicated only for meralgia paresthetica (lateral femoral cutaneous nerve entrapment) after conservative management failure, OR for pain control after total hip arthroplasty. 1

• The patient has NOT undergone total hip arthroplasty, which is the only indication where this block is recommended for hip pain 1
• The patient's diagnosis is trochanteric bursitis and hip pain, NOT meralgia paresthetica (lateral femoral cutaneous nerve entrapment) 2
• There is no documentation of lateral thigh numbness, burning, or paresthesias characteristic of meralgia paresthetica 2
• The clinical presentation describes hip and groin pain with trochanteric tenderness, which does not match the lateral thigh distribution of the lateral femoral cutaneous nerve 2, 3

Greater and Lesser Trochanteric Bursa Injections with Ultrasound Guidance (CPT 20611,76942)

These procedures are NOT medically necessary because Aetna CPB 0952 explicitly lists both iliotibial band bursa injection and trochanteric bursa injections as "unproven" for ultrasound guidance benefit. 4

• While trochanteric bursa injections themselves may have therapeutic value for greater trochanteric pain syndrome, the policy specifically states ultrasound guidance provides "no proven benefit" for these injections 4
• The patient does meet clinical criteria for trochanteric bursitis based on examination findings and MRI confirmation of gluteus medius/minimus pathology 2, 3
• However, the request specifically asks for ultrasound-guided injections (CPT 76942), which the policy deems unproven 4
• Landmark-guided injections would be the appropriate alternative if bursa injections were pursued, as cadaveric studies show comparable accuracy (67% vs 92%, not statistically significant) 4

Myofascial Trigger Point Injections (CPT 20553)

These procedures are NOT medically necessary because the patient fails to meet the mandatory 3-month symptom duration criterion specified in Aetna CPB 0016.

Critical unmet criteria:

• Symptom duration requirement NOT MET: The policy explicitly requires symptoms persisting for "more than 3 months" 1
• The documentation states "persistent pain" but provides no specific timeframe for symptom duration 5
• Without documented evidence of >3 months of symptoms, this criterion cannot be verified as met 1, 5

Additional concerns:

• The 2014 Journal of Neurosurgery guidelines provide Grade B recommendation that trigger point injections "are not recommended in patients with chronic low-back pain without radiculopathy from degenerative disease of the lumbar spine because a long-lasting benefit has not been demonstrated" 1
• The 2023 American Family Physician review states trigger point injections "should be reserved for patients whose myofascial pain has been refractory to other measures" and emphasizes less invasive strategies first 5
• While the patient has tried physical therapy, the documentation does not specify the duration or intensity of conservative treatment 5

Iliotibial Band Injections

This procedure is NOT medically necessary because Aetna CPB 0952 explicitly lists iliotibial band bursa injection as "unproven" for ultrasound guidance benefit.

• The policy provides no coverage determination for iliotibial band injections themselves, only stating ultrasound guidance is unproven 4
• There is insufficient high-quality evidence supporting iliotibial band injections for hip pain 2

Policy Violation: Multiple Simultaneous Invasive Procedures

The request violates fundamental pain management principles by requesting multiple invasive procedures simultaneously rather than following a stepwise approach. 1

• The 2010 ASA guidelines on chronic pain management emphasize multimodal interventions but do not support simultaneous multiple invasive procedures without prior individual assessment 1
• Best practice requires attempting one invasive modality at a time to assess individual efficacy and avoid confounding results 1, 5
• The patient should undergo a trial of ONE procedure first, with response assessment before considering additional interventions 1, 5

Recommended Appropriate Pathway

The clinically appropriate sequence would be:

1. Complete adequate conservative treatment duration: Ensure minimum 6 weeks of structured physical therapy, NSAIDs, and activity modification are documented 1, 2

2. Single procedure trial: If conservative measures fail after appropriate duration, consider ONE of the following:

   • Landmark-guided (not ultrasound-guided) trochanteric bursa injection for confirmed trochanteric bursitis 2, 3, 4
   • Sacroiliac joint injection if SI joint criteria are fully met (currently NOT met - see below) 1

3. Reassessment: Evaluate response to single intervention before considering additional procedures 1, 5

Additional Unmet Criteria for Sacroiliac Joint Injections

While not the primary question, the documentation also fails to meet criteria for SI joint injections:

• Duration requirement NOT MET: No documentation of >3 months SI joint pain 1
• Physical examination maneuvers NOT MET: Documentation does not specify performance of at least 3 of 5 required provocative tests (Compression, P4/Thigh Thrust, Patrick's/FABERE, Distraction, Gaenslen's) 1
• Exclusion of other causes NOT MET: The MRI shows significant lumbar pathology (L3-4 Grade I anterolisthesis, L4-5 bilateral foraminal stenosis with nerve root contact, L5-S1 foraminal stenosis) that has not been adequately ruled out as the pain source 1, 6

Critical Clinical Pitfalls

• Competing diagnoses: The extensive lumbar spine pathology (anterolisthesis, foraminal stenosis, facet arthropathy) may be the primary pain generator rather than hip pathology 7, 6
• Referred pain: Hip pain can be referred from lumbar spine pathology, and vice versa - the spine pathology must be addressed before attributing all symptoms to hip sources 7, 6
• Inadequate conservative treatment documentation: The timeframe and intensity of conservative measures are not clearly documented 1, 2, 5