I. Disclaimer

This document is intended to be used as a reference for non-VA providers and is not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice. 

II. Clinical Determinations and Indications

1. Indications for Trigger Point Injections  
   Trigger point injections (TPIs) for pain conditions with demonstrated trigger points are indicated for the treatment of certain musculoskeletal pain or myofascial pain syndromes. 

1. Treatment of Pain with Trigger Points  
2. Trigger point injections for musculoskeletal pain or myofascial pain syndromes may be considered medically necessary/covered when ALL the following criteria are met and documented: 
   • Presence of trigger points that are tender, palpable, and localized to a region in a taut band of muscle on physical exam 
   • Evidence of a neurological, orthopedic, or musculoskeletal system evaluation, which includes a description of pain (location, quality, severity, duration, timing, context), followed by a physical examination of associated signs and symptoms 
   • Trigger point injections are provided in conjunction with a comprehensive treatment plan, which may include pain management, physical therapy, and/or a home exercise program 
3. Subsequent Trigger Point Injections  
4. Repeat TPIs on previously injected trigger points may be considered medically necessary/covered when ALL the following are met and documented by the treating provider and/or referring clinician: 
   • Confirmed ongoing diagnosis of the original condition for which treatment was initiated 
   • Clinical reassessment showing therapeutic response or clinical benefit from prior sessions  
   • Consistent pain relief lasting approximately six weeks after the most recent previous TPI 
   • Updated treatment plan that outlines the following:  
     • Specific areas targeted for continued therapy 
     • Expected clinical outcomes 
   • Refer to section II.c. of this CDI for additional information on session limitations 
5. Quality of Care Recommendations 
   • When any substance is injected during the procedure, the exact substance, concentration, and volume must be documented in the medical record and billed appropriately 
   • Document the anatomical site(s), number of injections, and technique used 
   • Avoid unnecessary additives or substances without proven benefit 

The use of ultrasound guidance to locate a trigger point site may be considered medically necessary/covered when both of the following conditions are met: 

• A documented indication for use 
• Trigger point injections are conducted in areas near high-risk tissues (risk of neural, vascular, pulmonary, or visceral injury) or in trigger points located in deeper anatomic locations 

2. Limitations/Exclusions
3. Trigger point injections are not indicated and therefore considered not medically necessary and not covered for musculoskeletal pain or myofascial pain syndromes if ANY of the following are applicable: 

• Presence of systemic infections or infections at the site of injection 
• Presence of other unstable medical conditions  

Conditions/indications for which TPIs are not medically necessary and not covered include, but are not limited to, the following: 

• Widespread muscle tenderness, unless specific clinical criteria outlined in section II.a.i. are met 

Trigger point injections performed with the substances listed below are unproven and considered not medically necessary and not covered. These include, but are not limited to the following:  

• Biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.)  
• Medical injectate/irritant solutions (e.g., botulinum toxin, glucose/dextrose solutions, etc.)  
• Naturopathic, herbal, or homeopathic substances (e.g., herbal substances, Vitamin B12, etc.) 
• Any injection substance not approved by the Food and Drug Administration (FDA) 

For all other conditions or indications not listed in section II.a. of this document, trigger point injections are considered not medically necessary and not covered due to insufficient evidence of efficacy and safety. 

3. Session Limitations
4. Trigger point injections may be considered medically necessary/covered for up to six sessions for the indications in section II.a., provided all applicable clinical criteria are met and subject to the following limitations: 
   • Coverage is limited to a maximum of six sessions per calendar year, with injections performed no more than once every 30 days 
   • Additional sessions beyond the limit require reevaluation with the submission of a Request for Service form to the local VA medical facility  
   • All services must be provided by a licensed practitioner and documented as medically necessary in accordance with clinical guidelines 

4. Description of Treatment
5. Trigger point injections are a medical procedure involving the insertion of a needle, with injection (for example local anesthetic or normal saline), into a hyperirritable spot within a palpable taut band of skeletal muscle that produces local and/or referred pain when stimulated. Trigger points are typically identified through clinical examination and palpation. Trigger point injections are used in conjunction with a comprehensive treatment plan to manage myofascial pain associated with trigger points. Trigger point injections are intended to relieve pain and facilitate mobility in patients with myofascial pain syndrome who have not responded to other conservative therapies to treat trigger points. 

Trigger point injections are intended to inactivate the trigger point, alleviate pain, and facilitate mobility, enabling participation in physical therapy or other rehabilitation modalities. Trigger point injections are not used as a stand-alone therapy but as part of a comprehensive treatment plan when conservative measures (physical therapy, activity modification, or pharmacologic treatments) have failed or are not feasible, or as a part of a comprehensive treatment plan. 

Typically, TPIs are limited in frequency and number to minimize unnecessary risk. The procedure may involve one or multiple injections per session, and treatment intervals are guided by clinical response, generally with a maximum of four to six sessions per year. Trigger point injections are not indicated for widespread muscle tenderness, without evidence of trigger points. 

III. Background and Supporting Information

The following information is for reference purposes only in accordance with the medical benefits package outlined in 38 C.F.R. § 17.38 (b). Each subsection supports VA’s determinations for medical necessity and alignment with generally accepted standards of medical practice. 

1. Background Information
   Trigger points are discrete, hyperirritable locations within a palpable taut band of skeletal muscle. Trigger points produce local and/or referred pain when stimulated, and are identified through clinical evaluation, including palpation. Trigger points develop in the center of muscle fibers, and are palpable nodules within tight muscle bands, ranging from 2-10 mm in size. Trigger points are characterized by the presence of a taut band of skeletal muscle resulting in localized or referred pain, muscle tightness, restricted motion, and tenderness. Distinct from trigger point injections is an intervention called dry needling. Dry needling may refer to the use of solid or filiform needles inserted into myofascial trigger points to elicit a local twitch response. Dry needling may also include the use of hypodermic needles, without injectate, inserted directly into myofascial trigger points to elicit local twitch responses and mechanically disrupt tissue. In contrast, a trigger point injection employs a hollow needle, with injection, into the trigger point to achieve pain relief. 

Trigger points can cause significant discomfort and are often associated with chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. A comprehensive treatment plan is used to treat trigger point-related pain and may include physical therapy, chiropractic therapy, pharmacological therapy, massage, and other conservative therapies in conjunction with trigger point injections (TPIs). Use of botulinum toxin for trigger points is not supported for routine use based on current evidence. 

2. Research, Clinical Trials, and Evidence Summaries
   The North American Spine Society (NASS), the American Society of Anesthesiologists Task Force on Chronic Pain Management (ASA), and the American Society of Regional Anesthesia and Pain Medicine have congruent practice guideline conclusions regarding the use of TPIs. Each professional society’s practice guidelines are based upon multiple meta-analyses and support the efficacy of TPIs for chronic pain management, specifically myofascial pain, with the presence of trigger points. The practice guidelines indicate that there is insufficient evidence to evaluate the efficacy of TPIs compared to interventions consistent with Level V evidence (i.e. studies with little or no systematic empirical evidence). Thus, NASS, ASA, and the American Society of Regional Anesthesia and Pain Medicine determined that current evidence is inadequate to support or oppose the use of TPIs for treating low back pain, but did conclude that substance injections for trigger points does not impact treatment outcomes. However, observational studies suggest that TPIs may provide relief for patients with myofascial pain for assessment periods ranging from one to four months when examining Levels II, III, or IV evidence (i.e. recommended findings that are generally consistent across numerous studies). The three independent meta-analyses consistently concluded that TPIs can be considered as part of a multimodal approach to pain management for patients with myofascial pain, although more rigorous studies are needed to establish their definitive efficacy. 

De Andrés, et al., (2010) conducted a prospective, randomized, double-blind, controlled trial evaluating the efficacy of type-A botulinum toxin (BTX-A) for treating lumbar myofascial pain in 27 patients with mechanical low back pain due to bilateral myofascial pain syndrome involving the iliopsoas and/or quadratus lumborum muscles. Each patient received a bilateral, fluoroscopically guided injection, with BTX-A administered to one side and a control drug (NaCl 0.9% or bupivacaine 0.25%) to the other. The study used five questionnaires to assess the effects on daily life activities and psychological status. The results indicated that BTX-A did not significantly reduce visual analog scale scores more than the control treatments, nor did it significantly improve daily life activities or psychological status. The study concluded that while BTX-A decreased post-intervention pain relief, its high cost and the small differences compared to control treatments suggest its use should be reserved for patients with pain refractory to other invasive treatments. 

3. Medicare Coverage Determinations
4. Available Medicare national and local coverage determinations are listed below as a resource. VA and Medicare are governed by separate laws and regulations; thus, VA coverage determinations may be different. 

NCD Number	Name	Effective Date
None	N/A	N/A

LCD Number	Contractor	Original/Revision Effective Date
L35010	Novitas Solutions, Inc.	09/01/2022
L39713	WPS Insurance Corporation	01/29/2026
L39656	CGS Administrators, LLC	04/01/2024
L39662	National Government Services	04/01/2024
L34211	Noridian Health Solutions, LLC	10/23/2025
L39671	Palmetto GBA	03/31/2024

• NCD: National Coverage Determination
• LCD: Local Coverage Determination

4. TRICARE Policy Manual
5. Available TRICARE coverage determinations are listed below as a resource. VA and TRICARE are governed by separate laws and regulations; thus, VA coverage determinations may be different. 

TRICARE Policy Manual 6010.60-M, Chapter 04, Section 20.1, Nervous System 

TRICARE Policy Manual 6010.63-M, Chapter 04, Section 6.1, Musculoskeletal System   

5. Health Care Procedural Coding Information
6. The following CPT^®/HCPCS codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) code updates may occur more frequently than CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for medical necessity. 

The following CPT codes may be considered medically necessary/covered if the indications and clinical criteria outlined in section II.a. are met. Additional codes may also apply. 

CPT Code	Description
20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles
76942	Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT copyright 2026 American Medical Association. All rights reserved. 

IV. Definitions

Term	Definition
Anesthetic	A drug or other substance that causes a loss of feeling or awareness in a localized or regional portion of the body
Conservative therapy	Initial treatments for musculoskeletal pain that may include physical therapy, medications, ergonomic changes, and lifestyle modification
Myofascial pain	A chronic musculoskeletal pain condition characterized by regional muscle pain associated with trigger points, resulting in local and referred pain and often reduced range of motion
Myofascial pain syndrome	A chronic regional pain disorder which may include one or more trigger points in muscle or fascia, leading to localized or referred pain, muscle tightness, and restricted movement
Referred pain	Pain perceived at a location other than the site of the pain generator, following predictable patterns
Taut band	A palpable, tense band of skeletal muscle fibers that may contain a trigger point or tender point, which may contribute to pain and dysfunction
Trigger point	A discrete, hyperirritable spot within a taut band of skeletal muscle that is painful on compression and can produce characteristic referred pain, motor dysfunction, and autonomic phenomena
Trigger point injection	A medical procedure involving the insertion of a needle, with injection, into a trigger point.

V. References

Anwar, N., Wei, X., Jie, Y., Hongbo, Z., Jin, H., & Zhu, Z. (2024). Current advances in the treatment of myofascial pain syndrome with trigger point injections: A review. Medicine, 103(40), e39885.  

Appasamy, M., Lam, C., Alm, J., & Chadwick, A. L. (2022). Trigger point injections. Physical medicine and rehabilitation clinics of North America, 33(2), 307.  

Benzon, H. T., Connis, R. T., De Leon-Casasola, O. A., et al. (2010). Anesthesiology, 112(4), 810–833.  

Benzon, H. T., Elmofty, D., Shankar, H., Rana, M., Chadwick, A. L., Shah, S., … & Shanthanna, H. (2024). Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections-guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society. Regional Anesthesia & Pain Medicine.  

Bodine, N. (2023). An overview of myofascial pain syndrome with a focus on trigger point injection. The Nurse Practitioner, 48(11), 18-25.  

De Andrés, J., Adsuara, V. M., Palmisani, S., Villanueva, V., & López-Alarcón, M. D. (2010). A double-blind, controlled, randomized trial to evaluate the efficacy of botulinum toxin for the treatment of lumbar myofascial pain in humans. Regional anesthesia and pain medicine, 35(3), 255–260.  

Debrosse, M., Shergill, S., Shah, A., Patel, K., Gulati, A., & Rajput, K. (2022). Trigger point injection therapies for chronic myofascial neck and back pain: A systematic review. Interventional Pain Medicine, 1(3), 100076.  

Defense Health Agency (1985, August 29). Nervous System. TRICARE Policy Manual 6010.60-M. Chapter 04, Section 20.01. Retrieved 04/15/2025. 

Defense Health Agency (1985, August 26). Musculoskeletal System. TRICARE Policy Manual 6010.63-M. Chapter 04, Section 6.1. Retrieved 02/09/2026. 

Garvey, T. A., Marks, M. R., & Wiesel, S. W. (1989). A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine, 14(9), 962–964. 

Hamzoian, H., & Zograbyan, V. (2023). Trigger point injections versus medical management for acute myofascial pain: A systematic review and meta-analysis. Cureus, 15(8).  

North American Spine Society (2020). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of low back pain. 

Roldan, C. J., Osuagwu, U., Cardenas-Turanzas, M., & Huh, B. K. (2020). Normal Saline Trigger Point Injections vs Conventional Active Drug Mix for Myofascial Pain Syndromes. The American journal of emergency medicine, 38(2), 311–316.  

Sayed, D., Grider, J., Strand, N., Hagedorn, J. M., Falowski, S., Lam, C. M., … & Deer, T. (2022). The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guideline of interventional treatments for low back pain. Journal of pain research, 3729-3832.  

VI. CDI History/Revision Information

Date	Summary of Updates
08/01/2026	New CDI created describing medically necessary and not medically necessary indications

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