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LCD L33912: Trigger Point Injections

LCD L33912, Trigger Point Injections, is the Local Coverage Determination that First Coast Service Options, Inc. applies to claims from 3 states (FL, PR, VI), effective 2026-09-06 and first in force 2015-10-01. The policy text runs 376 words, and its billing and coding article A57114 lists 2 ICD-10-CM codes that support medical necessity for 15 procedure codes. 6 other contractors publish a policy with the same title, so the criteria that apply depend on where the service is furnished.

QuickIntell editorial content · Legacy registry date · Review not verified

Data effective
Data currency: Medicare Coverage Database LCD export release of September 24, 2026 (effective September 20, 2026). Next CMS release: weekly (Thursdays) for the MCD.
Contractor
First Coast Service Options, Inc.
States and territories
3
FL PR VI
Revision effective
2026-09-06
Original effective
2015-10-01
Policy text
376 words
Covered ICD-10 codes (articles)
2

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L33912
ContractContractorTypeStates
09101First Coast Service Options, Inc.A and B MACFL
09201First Coast Service Options, Inc.A and B MACPR VI
09102First Coast Service Options, Inc.A and B MACFL
09202First Coast Service Options, Inc.A and B MACPR
09302First Coast Service Options, Inc.A and B MACVI

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57114 (Billing and Coding: Trigger Point Injections) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A57114: Billing and Coding: Trigger Point Injections (Billing and Coding, effective 2026-09-06)

Covered ICD-10-CM codes
2
1 group
Non-covered ICD-10-CM codes
1
Procedure codes listed
15
Full article
cms.gov record
First 2 covered ICD-10-CM codes in A57114
ICD-10-CMDescription (FY2027)
M79.12—
M79.18—

Procedure codes: 20552, 20553, J0585 (Injection, Onabotulinumtoxina, 1 Unit), J0586 (Injection, Abobotulinumtoxina, 5 Units), J0587 (Injection, Rimabotulinumtoxinb, 100 Units), J0588 (Injection, Incobotulinumtoxin A, 1 Unit), J0589 (Injection, Daxibotulinumtoxina-Lanm, 1 Unit), J0702 (Injection, Betamethasone Acetate 3 Mg And Betamethasone Sodium Phosphate 3 Mg), J1010 (Injection, Methylprednisolone Acetate, 1 Mg), J1100 (Injection, Dexamethasone Sodium Phosphate, 1 Mg), J2919 (Injection, Methylprednisolone Sodium Succinate, 5 Mg), J3121 (Injection, Testosterone Enanthate, 1 Mg), J3300 (Injection, Triamcinolone Acetonide (Triesence), Preservative Free, 1 Mg), J3301 (Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg), J7040 (Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)).

Coverage indications, limitations and medical necessity

Covered Indications

Trigger Point Injections (TPIs) will be considered reasonable and necessary to treat myofascial pain caused by a trigger point when the following requirements are met:

• There is a focal area of pain in skeletal muscle, directly associated with a palpable, firm nodule within a taut band of muscle fiber 1 ; AND

• Physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber which is palpable and more firm than normal consistency and surrounding muscle, with or without local twitch response and referred pain 1 ; AND

• Patients must be participating in a multimodal program with contemporaneous documentation supporting consistent, active participation in a prescribed pain management plan. 2

Limitations

The following are considered not reasonable and necessary:

• The use of ultrasound (US) guidance for the performance of TPI. 3

• The use of fluoroscopy or magnetic resonance imaging (MRI) guidance for performance of TPI (see rationale for determination).

• A TPI involves the use of local anesthetics (LA) and does not include the use of corticosteroids, saline, biologicals, prolotherapy, platelet-rich plasma (PRP), botulinum toxin, or any other injectates. 2,3 (see Related National Coverage Documents)

• TPI for treating low back pain, 4,5 fibromyalgia, 6 or any other condition not meeting the diagnostic criteria for myofascial pain syndrome (MPS) in absence of trigger points. 2

• The routine performance of more than three (3) TPI sessions within a rolling 12-month period is not reasonable and necessary. In exceptional, clinically appropriate circumstances, a maximum of four (4) sessions may be justified. For such cases, providers must submit an attestation with the claim confirming that all coverage criteria outlined in this policy are met. Providers are advised to consult the Billing and Coding Article for guidance on attestation and documentation requirements. 13

• Five (5) or more TPI sessions per rolling 12-month period per beneficiary. 7(pp21-29)

Notice: Services performed for any given diagnosis must meet all the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Compliance with the provisions in this LCD may be monitored and addressed through post-payment data analysis and subsequent medical review audits.

Summary of evidence (opening)

History, Background, and/or General Information

Definitions:

Dry Needling (DN) - A technique that involves the insertion of solid filament needles into the skin and underlying tissue to disrupt pain sensory pathways and relax contracted fibers.

Fibromyalgia – A chronic pain syndrome which presents with tender points, somatic symptoms and widespread musculoskeletal pain associated with the development of peripheral and central sensitization.

The contractor cites 164 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective
2015-10-01
Current revision effective
2026-09-06
MCD version
23
Derived from
L29199

Other related documents: A60437 (Response to Comments).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the First Coast Service Options, Inc. hub lists every other active policy from the same contractor.

The same policy title at other contractors

Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.

L34211
Noridian Healthcare Solutions, LLC · 18 states · revised 2025-10-23 · 10 covered codes
L35010
Novitas Solutions, Inc. · 12 states · revised 2026-09-06 · 2 covered codes
L39656
CGS Administrators, LLC · 2 states · revised 2024-04-01 · 10 covered codes
L39662
Wellpoint Federal · 13 states · revised 2026-04-01 · 10 covered codes
L39671
Palmetto GBA · 7 states · revised 2024-03-31 · 10 covered codes
L39713
Wisconsin Physicians Service Insurance Corporation · 48 states · revised 2026-01-29 · 10 covered codes

Frequently asked questions

What does LCD L33912 cover?

Trigger Point Injections (TPIs) will be considered reasonable and necessary to treat myofascial pain caused by a trigger point when the following requirements are met: The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L33912 apply to?

First Coast Service Options, Inc. applies it to Medicare claims in FL, PR, VI. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L33912?

The companion billing and coding article A57114 lists 2 ICD-10-CM codes in 1 group that support medical necessity and 1 that do not; the first 2 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L33912?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.