Are trigger point injections (CPT 20553) every 3 months medically necessary for a 36-year-old female with bilateral occipital neuralgia and migraines, who has previously received occipital nerve blocks (CPT 64405) with short-lasting results and is currently taking Aimovig (erenumab) and Nurtec (rimegepant)?

Trigger Point Injections Are NOT Medically Necessary in This Case

The requested trigger point injections (CPT 20553) should be denied because the patient does not meet established criteria for this procedure: there is no documentation of identified trigger points on physical examination, no diagnosis of myofascial pain syndrome, and no evidence that conservative treatments were attempted and failed before considering invasive procedures. 1

Critical Missing Documentation

The case lacks fundamental requirements for trigger point injection approval:

• No trigger points identified on physical exam: The documentation does not describe palpation findings of discrete, focal, hyperirritable spots in taut bands of skeletal muscle, which are the defining physical findings required for trigger point diagnosis 2, 3

• No myofascial pain syndrome diagnosis: The patient's diagnoses are bilateral occipital neuralgia and chronic migraine—neither of which are indications for trigger point injections 1

• Insufficient conservative treatment trial: While the patient has tried Aimovig (erenumab), Nurtec (rimegepant), and OTC supplements, there is no documentation of adequate trials of NSAIDs, physical therapy, massage, or osteopathic manual medicine, which should be first-line treatments before invasive procedures 3

Why Occipital Nerve Blocks Are Appropriate But Trigger Point Injections Are Not

The occipital nerve blocks (CPT 64405) are correctly certified because:

• The VA/DoD guidelines suggest greater occipital nerve blocks for short-term treatment of migraine 1
• The patient has documented occipital neuralgia, which is a specific indication for occipital nerve blocks 4
• The 3-month interval between injections aligns with guideline recommendations 1
• Occipital nerve blocks have demonstrated efficacy with symptom relief lasting weeks to months 4

However, trigger point injections lack justification because:

• Trigger point injections should be reserved for patients with myofascial pain refractory to other measures, not as routine add-ons to nerve blocks 3
• No single pharmacologic agent used in trigger point injections has proven superior to placebo 3
• The patient's short-lasting results from previous treatments suggest the underlying pathology is not trigger point-mediated 2

Evidence-Based Treatment Algorithm for This Patient

Given the patient's chronic migraine with almost daily headaches despite current preventive therapy, the appropriate next steps are:

1. Optimize preventive pharmacotherapy before adding more invasive procedures:

   • Consider adding or switching to proven preventive agents such as topiramate, valproate, or memantine 1
   • For chronic migraine specifically, onabotulinumtoxinA injection is suggested by guidelines (not trigger point injections) 1

2. Continue occipital nerve blocks at 3-month intervals as already certified, since they provide some benefit even if short-lasting 1, 4

3. Address acute treatment optimization:

   • The patient is already on rimegepant (Nurtec), which can be used both acutely and preventively 5, 6
   • Ensure proper acute treatment with combination therapy (triptan plus NSAID or acetaminophen) for breakthrough attacks 1

4. Implement non-pharmacologic interventions:

   • Physical therapy is suggested for management of migraine and cervicogenic headache 1
   • Aerobic exercise or progressive strength training for prevention of migraine 1

Common Pitfalls to Avoid

Medication overuse headache risk: With almost daily migraines, this patient is at high risk for medication overuse headache, defined as headache occurring ≥15 days per month for ≥3 months due to overuse of acute medication 1. The threshold is ≥10 days per month for triptans 1

Inappropriate use of trigger point injections: Trigger point injections are often overutilized without proper indication. They should only be considered when: (1) actual trigger points are identified on examination, (2) symptoms have persisted >3 months despite conservative care, (3) they are part of a comprehensive pain management program including physical therapy, and (4) conservative treatments have failed 1

Frequency violations: The proposed every-3-month frequency for trigger point injections, while meeting spacing guidelines, is still inappropriate without meeting the fundamental indication criteria 1

Recommendation

Non-certification of CPT 20553 x2 is appropriate. The patient should continue with the already-certified occipital nerve blocks (CPT 64405 x2) every 3 months, optimize preventive medications (consider onabotulinumtoxinA for chronic migraine rather than trigger point injections), ensure adequate acute treatment strategies, and incorporate physical therapy and lifestyle modifications 1, 3.