Are Trigger Point Injections Covered by Medicare?

Medicare Part B (which, along with Part A, is often called “Original Medicare”) and all Medicare Advantage (Medicare Part C) plans cover trigger point injections if you meet certain health requirements. 

If you have Original Medicare (Medicare Part A and Part B), you may be able to get help paying for the Medicare Part B coinsurance costs and other out-of-pocket Medicare costs by applying for a Medicare Supplement plan – also called a Medigap plan.

When Does Medicare Pay for Trigger Point Injections?

Medicare covers trigger point injections when a beneficiary has been diagnosed with myofascial pain syndrome (MPS). This diagnosis is generally made through a physical examination along with a review of the beneficiary’s medical history. 

Some of the signs and symptoms that may lead to an MPS diagnosis include:

• An injury to the affected area
• Restricted range of motion
• Muscular deconditioning 
• Focal tenderness
• Palpable taut band of muscle in the affected area
• Local taut response to snapping palpation
• Reproduction of pain pattern upon stimulation of trigger point
• Distribution pattern of pain that is consistent with the referral pattern of trigger points

Medicare coverage for some treatments may be determined by whether the care is considered medically necessary. Once a diagnosis of MPS has been made, a trigger point injection is determined to be medically necessary if any of the following are true:

• Joint movement is mechanically blocked
• Non-invasive medical management has been tried unsuccessfully
• Other treatments, such as medication or physical therapy, are being initiated

Medicare considers each location of the body where an injection was made to be a single service, regardless of the number of injections made at the location. 

How Much Do Trigger Point Injections Cost With Medicare?

When trigger point injections are covered by Medicare Part B, beneficiaries are typically responsible for paying a 20% coinsurance cost after they meet their Part B annual deductible. As mentioned above, Part B coinsurance costs may be covered by a Medicare Supplement Insurance (Medigap) plan. 

Medicare Part C (Medicare Advantage plans) are a different type of private Medicare insurance than Medicare Supplement plans. While all Medicare Advantage plans cover qualified trigger point injections, the exact way it’s covered may differ by plan. 

Medicare Advantage plans are required to cover the same benefits as Medicare Part A and Part B, but they may charge differing amounts of coinsurance, copayments and deductibles.

Does Medicare Cover Acupuncture or Prolotherapy for Pain?

Acupuncture and prolotherapy are two pain treatment options that some people may consider. Medicare covers acupuncture to treat your pain if you meet certain health requirements, but Medicare does not cover prolotherapy in most cases, as it is currently considered an “alternative” medical treatment.

• While trigger point injections use a needle to deliver local anesthetics, steroids or inflammatory drugs to an area of the body affected by pain, acupuncture also uses a needle to target areas affected by pain and inflammation, but nothing is injected into the body other than the needle itself. Most commonly, needles are inserted into the paraspinal muscles. 
  
  Medicare Part B covers up to 12 acupuncture visits in a 90-day period for chronic low back pain, along with an additional 8 visits if improvement is shown. No more than 20 sessions may be covered in a year. Medicare Advantage plans may provide additional coverage of acupuncture. 
  
  
• While trigger point injections use artificial agents, prolotherapy injects natural irritants such as dextrose solution to trigger a healing response from the body. The effectiveness of prolotherapy remains in question by the medical community and is categorized as alternative medicine. For these reasons, it is not covered by Medicare. 

If you have Medicare Part A and Part B and receive Medicare-covered trigger point injections or acupuncture, a Medicare Supplement plan could help you pay the coinsurance, copays or deductible costs you may face.