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Experiencing muscle pain is, at best, an inconvenience and, at worst, interferes greatly with our daily lives. This is especially true with severe pain. Luckily, there are ways to treat it. Trigger point injections are one method people use to combat severe muscle pain.
Is this a treatment you are thinking about getting? If so, you may be wondering “does Medicare cover trigger point injections?” In this article, we answer that question in clear, plain English. You will also find the average costs of trigger point injections if you have to pay for it yourself.
Does Medicare Cover Trigger Point Injections?
The short answer is yes; Medicare will cover the cost of a trigger point injections session. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your trigger point injections. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for trigger point injections. Parts A and B provide coverage for your trigger point injections if it is considered medically necessary. The treatment must also be first ordered by your healthcare provider for Original Medicare to provide coverage.
In order for Original Medicare to provide coverage for your trigger point injection, you need to follow these requirements:
- An evaluation is required leading to the diagnosis of the trigger point in the patient’s muscle/s
- A document showing/stating the muscles affected
- A reason why trigger point injections are selected as a treatment option and stating if it will be used as an initial treatment or a subsequent option
- For trigger point injection in the tendon sheaths, ligaments, ganglion cysts, carpal, and tarsal tunnels, there must be a procedural note which states why the reason for the injection of the following sites are necessary
Although Original Medicare provides coverage for trigger point injections, as of 2021 there is no National Coverage Determination, or NCD, for this treatment. Instead, there is a Local Coverage Determination for it.
To receive coverage for trigger point injections, you may use either Medicare CPT code 20552 or 20553. 20552 is for one or two muscle groups injected while 20553 is for three or more muscle groups. You may only bill for one of the two codes and not both at the same time.
According to the CMS website, “Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).”
Part C Coverage for Trigger Point Injections
Medicare Advantage plans (Medicare Part C) also provide coverage for trigger point injections. They cover everything Original Medicare covers (it’s the law – they have to!). But they also provide coverage for some things that Original Medicare does not. What those things are and how much the costs for them are will depend on the Part C plan you have.
How Much Do Trigger Point Injections Cost?
On average, trigger point injections cost between $250 to $450 if you have to pay for them yourself. This cost will vary depending on the provider and number of injections you are receiving.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare cover testosterone pellets?