HHO-DE-MP-1253-002 Ultrasound Guidance for Joint, Tendon, Tendon Sheath, and Trigger Point Injections

Medical Policy

D-1253-002

Policy Id

HHO-DE-MP-1253

Topic

Ultrasound Guidance for Joint, Tendon, Tendon Sheath, and Trigger Point Injections

Section

Archived Policies

Effective Date

Jun 16, 2025

Issued Date

May 16, 2025

Last Revision Date

05/2025

Annual Review

05/2026

Prepared By

J Fletcher

THIS IS NO LONGER AN ACTIVE POLICY. POLICY WAS ARCHIVED ON 06/16/2025.

DISCLAIMER

Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.

Purpose

This medical policy outlines Highmark Health Options services for Ultrasound Guidance for Joint, Tendon, Tendon Sheath, and Trigger Point Injections.

Definitions

Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.

Ultrasound guidance – A radiology procedure that allows clinicians to provide accurate needle placement for injection and/or aspiration procedures.

Policy Position

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

Images performed must be saved for future review.

HHO considers ultrasound (US) guidance medically necessary for the following procedures (not an all-inclusive list):

Adductor canal nerve block
Arterial line placement
Axillary brachial plexus nerve block
Baker's cyst, after failure of unguided procedure
Breast mass biopsy (see CPB 0269 - Breast Biopsy Procedures)
C5-C7 interscalene nerve block
Carpal tunnel injection
Carpal tunnel release
Central venous access (internal jugular, femoral)
De Quervain tendinopathy, after failure of unguided procedure
Elbow joint injection or aspiration, after failure of unguided procedure
Embryo transfer (see CPB 0327 - Infertility)
Endovenous laser ablation of the saphenous vein (ELAS) (see CPB 0050 - Varicose Veins)
Fascia iliaca block for the management of post-operative pain following hip and knee surgeries, and repair of femur fracture
Femoral nerve block for post-operative knee pain
Hepatic mass biopsy
Hip joint injection or aspiration
Iliohypogastric nerve block
Ilioinguinal nerve block
Infraclavicular nerve block for surgery of the distal arm and hand
Intercostobrachial nerve block
Inter-digital neuroma injection
Interscalene nerve block (including for shoulder dislocation reduction)
Intraabdominal or intrapelvic mass biopsy
Intrathecal drug delivery
IPACK nerve block for pain control after anterior cruciate ligament (ACL) repair or total knee arthroplasty
Ischial bursa and gluteus medius injection
Lateral femoral cutaneous nerve block for meralgia paresthetica (lateral femoral cutaneous nerve entrapment) (see CPB 0863 - Nerve Blocks)
Liver cyst aspiration
Long head of the biceps injection for the treatment of tendinosis of the biceps
Lumbar puncture (see CPB 0628 - Spinal Ultrasound)
Metacarpophalangeal joint injection or aspiration
Metatarsophalangeal joint injection or aspiration
Needle placement, lavage, and debridement of calcific tendinosis of the shoulder
Nephrocutaneous access
Pancreatic mass biopsy
Pectoral nerve blocks (PECS I and PECS II) for post-operative pain control after breast surgery / sternotomy for cardiac surgery
Pectoralis nerve block (PEC 1 and PEC 2) for the management of post-operative pain following mastectomy
Piriformis muscle injection
Placement of vena caval filter (see CPB 0382 - Intravascular Ultrasound)
Placement of intracoronary endoluminal devices (see CPB 0382 - Intravascular Ultrasound)
Popliteal nerve block
Posterior glenohumeral (GH) joint injection or aspiration, after failure of unguided procedure
Pulmonary or thoracic mass biopsy
Prostate biopsy for prostate nodule or elevated PSA (see CPB 0001 - Transrectal Ultrasound)
Quadratus lumborum nerve block for post-operative pain control after abdominal surgery
Radiofrequency endovenous occlusion (VNUS) (see CPB 0050 - Varicose Veins)
Rectus sheath block and pecto-intercostal fascial block following cardiac surgery (e.g., aortic valve replacement)
Saphenous nerve block
Scapular thoracic bursitis injection
Sciatic nerve block
Serratus plane block for the management of post-operative pain following breast surgery or thoracotomy
Steroid injection into the gluteus maximus tendon
Subacromial bursal injection or aspiration, after failure of unguided procedure
Subpectoral nerve block (parasternal T2 to T6 intercostal block) for postoperative pain control
Subtalar joint injection or aspiration
Supraclavicular nerve block for primary regional anesthesia during surgeries, and post-operative pain control
Tibiotalar joint injection or aspiration, after failure of unguided procedure
Thyroid nodule biopsy
Transverse abdominis plane (TAP)-block for the management of post-operative pain following abdominal surgery
Wrist (radiocarpal) joint injection or aspiration, after failure of unguided procedure.

HHO considers US guidance of no proven benefit for the following procedures (not an all-inclusive list):

Acromioclavicular joint
Abductor digiti minimi injection
Adductor brevis and pectineus tendon injection for pain relief
Adductor longus tendon injection
Ankle bursa injection
Anterior medial ankle joint and tibialis posterior tendon sheath injection for foot pain
Anterior scalene/brachial plexus block for management of chronic pain
Aspiration of cyst(s) located in the inferolateral coccyx/sacral region
Aspiration of hematoma of the gastrocnemius
Botulinum toxin injection for the treatment of cervical dystonia, limb and paraspinal spasticity, migraine, or spasmodic torticollis
Calcaneal/retrocalcaneal bursa injection
Carpometacarpal (CMC) joint injection
Calcified medial collateral ligament injection
Clavi-pectoral fascial plane block
Collection of fluid for culture from the post-femoropopliteal bypass graft site
Costochondral joint
Deep peroneal nerve injection for peroneal neuritis
Diagnostic inguinal lymphangiography
Dorsal compartments of the wrist injection
Dorsal scapular nerve block
Endovascular treatment of subclavian artery disease (see CPB 0382 - Intravascular Ultrasound)
Epidural injections, including the transforaminal approach (see CPB 0016 - Back Pain - Invasive Procedures)
Erector spinae plane (ESP) block for the management of post-operative pain (see CPB 0863 - Nerve Blocks)
Extensor carpi ulnaris tendon injection
Facet joint injections (see CPB 0016 - Back Pain - Invasive Procedures)
Foot/heel injection for adventitious bursitis/capsulitis
Ganglion cyst injection of the wrist/wrist injection
Ganglion cyst injection or aspiration of the ankle, finger, shoulder, or tarsometatarsal joint
Gluteal nerve injection
Gluteal tendon sheath injections for hip and/or low back pain
Gluteus medius tendon injection
Hamstring tendon injection
Hematoma of thigh aspiration
Hematoma of should aspiration
Hydrodissection of the dorsal scapular nerve and middle/inferior trapezius, rhomboids for peripheral nerve entrapment/shoulder pain
Hydodissection of the Hoffa's fat pad (infra-patellar far pad), paratendon of the patellar tendon, and psoas
Hydrodissection of infrapatellar saphenous nerve, or scar tissue at the trapezius tendon region
Identification and aspiration of hematomas follwoing great saphenous vein surgery
Iliopsoas bursa injection
Iliopsoas tendon / tendon sheath injection
Iliopsoas band bursa injection
Iliotibial (IT) band hydrodissection / IT band injection for IT band pain
Inguinal subcutaneous fluid aspiration
Intercostal nerve block
Intraarticular injection for the management of shoulder impingement/pain
Ischial bursa injection for ischial bursitis
Ischial tuberosity peritendinous injection
Knee joint (except in morbidly obese individuals (BMI > 40))
Knot of Henry injection
Lateral epicondylitis injection
Lateral femoral cutaneous nerve block for the treatment of post-operative pain after total hip arthroplasty
Lateral pericapsular nerve group (PENG) nerve block during total hip arthroplasty
Latissimus dorsi injection
Lavage of the shoulder joint
Ligament sheath injections
Lumbar erector fascia injection
Lumbar plexus block with hydrodissection
Medial calcaneal nerve sheath injection
Median nerve block
Metatarsophalangeal and/or metatarsal cuneiform joint injection for the treatment of plantar fibromatosis (Ledderhose disease)
Multifidus lumborum injection for the treatment of low back pain
Myositis ossificans injection
Needle aspiration or injection of ganglion cyst of metatarsophalangeal (MTP) joint
Needle placement during aortography
Nuchal ligament and supraspinous ligament injection
Occipital nerve block (see CPB 0863 - Nerve Blocks)
Os trigonum syndrome injection
Paravertebral block for periacetabular osteotomy and diagnostic hip arthroscopy
Pectineus tendon injection
Percutaneous bursectomy of the pretibial tubercle bursa
Percutaneous tenotomy of the gluteus medius tendon for the treatment of hip tendinopathy
Perineal nerve block for spastic pelvic floor syndrome and pudendal neuralgia
Peritendon injection for the treatment of Achilles tendinopathy (including Kager’s fat pad, also known as pre-Achilles or pre-calcaneal fat pad)
Peroneal tendon sheath injection
Pes anserine bursa injection
Plantar fasciitis injections
Posterior tibial nerve block for plantar fasciitis
Pre-patellar bursa injection
Psoas tendon injection
Pudendal nerve block for the treatment of vulvodynia
Radial nerve block for post-operative pain management
Rectus abdominus muscle infiltration for palliative treatment of abdominal wall pain
Retinaculum of knee injection
Sacroiliac joint injection (see CPB 0016 - Back Pain - Invasive Procedures)
Saphenous vein access
Scapholunate ligament injection
Scar tissue injection after Dupuytren's cord excision surgery
Sclerotherapy for varicose veins (see CPB 0050 - Varicose Veins)
Semimembranosus tendon insertion injection
Subacromial bursitis injection
Subcutaneous seroma aspiration
Subfacial cyst anterior to the proximal talofibular joint, aspiration
Superficial cervical plexus block for post-operative pain control after left trans-mastoid endolymphatic shunt, (y)
Superficial radiation treatment of skin cancer
Superior cluneal nerve injections
Suprascapular nerve block
Tarsal tunnel injection
Tendon injection (other than those listed as medically necessary above)
Tendon scraping/neovessel albation for Achilles tendinosis
Tenotomy for the treatment of lateral epicondylitis
Tibiofibular joint injection
Trigger finger injection/trigger finger release with or without hydrodissection
Trigger point injections (see CPB 0016 - Back Pain - Invasive Procedures)
Trochanteric bursa injections
Upper trapezius injection
Viscosupplement injections (see CPB 0179 - Viscosupplementation).

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service: Outpatient

*20600	Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance.
20604	Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting.
*20605	Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance.
20606	Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting.
*20610	Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa); without ultrasound guidance.
20611	Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.
20550	Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”).
*20551	Injection(s); single tendon origin/insertion.
*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 muscle(s).
76942	Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
76882	Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.

*Prior authorization no longer required.

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.

References

A Randomized, Controlled, Double Blinded Study of Ultrasound Guided Corticosteroid Joint Injections in Patients with Inflammatory – Arthritis & Rheumatism – March 10, 2010, http://www3.interscience.wiley.com/journal/123318594/abstract?CRETRY=1&SRETRY=0

Current Procedural Terminology (CPT®), (2017) – American Medical Association

Daniels, E. W. et al. (2018) Existing Evidence on Ultrasound-Guided Injections in Sports Medicine. The Orthopaedic Journal of Sports Medicine, 6(2), 1-7. doi: 10.1177/2325967118756576

EnCoder Pro – Ingenix (2017)

Facets Claim System – SelectHealth (2017)

Knee Joint Injections: Watch for Ultrasound Guidance Denials, Highmark Medicare Service, May 28, 2010 http://news.aapc.com/index.php/2010/05/knee-joint-injections-watch-for-ultrasound-guidance-denials/

National Correct Coding Initiative (NCCI) (2017)

Medical & Reimbursement Policies