Trigger Point Injections denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 45-year-old female diagnosed as having fibromyalgia for approximately one and a half years. She first began treatment for this condition in July 2004 and received treatment until May 2005. The patient indicates she had symptoms six months prior to beginning acupuncture treatment. A request has been made for continued acupuncture and trigger point injections, which has been denied by the Health Plan.It appears the patient first received treatment for fibromyalgia in July 2004, which involved trigger point injections, massage and acupuncture. Based upon the records provided, it appears the patient has had approximately 39 treatments; 15 of these treatments involved acupuncture in addition to massage and trigger point injections.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for trigger point injections. A retrospective review shows that trigger point injections are effective in reducing pain scores compared to medical treatment. A study which looked at patients with headache who underwent trigger point injections concluded that the administration of trigger point injections using isotonic saline can effectively relieve headache intensity and safely improve quality of life. Finally, a review of cancer patients concluded that trigger point injection of a local anesthetic is safe and efficacious in inducing an immediate reduction in myofascial pain syndrome-related pain in patients with cancer.

Where the denial was upheld

Findings: The physician reviewer found that a patient with a diagnosis of lumbar spinal stenosis and myofascial pain has requested authorization and coverage for administration of spinal injections at up to four levels of the spine, including the cervical region, thoracic region, and lumbar region, in addition to trigger point injections (10 points) to be co-administered on the same date of service and scheduling of the injection appointments on an “as needed” basis based upon the patient’s severe pain and request for repeat injection(s). The records indicate that the patient has previously received trigger point injections that have included corticosteroids; the medical necessity and safety of the high number and volume of corticosteroid injections that might be administered with the requested injections on the same day is not clearly established.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for trigger point injections. . Findings: The physician reviewer found that a review of treatments and management of myofascial pain, Urits and colleagues noted that studies that compared trigger point injection effectiveness against a control with some therapeutic value, such as dry needling or saline trigger point injection, all found that local anesthetic trigger point injection was not a significantly better treatment even if it did result in patient improvement from baseline pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Trigger Point Injections, then check the rights and deadlines that apply to your plan.