Description
Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain.

For individuals who have myofascial trigger points associated with neck and/or shoulder pain who receive dry needling of trigger points, the evidence includes randomized controlled trials (RCTs) and a systematic review. The relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. As reported in the systematic review of literature published through 2013, only 1 of 8 studies found significantly greater reductions in pain with dry needling compared with other treatments. Two more recent RCTs comparing dry needling with manual therapy did not find significantly better outcomes after dry needling. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have myofascial trigger points associated with plantar heel pain who receive dry needling of trigger points, the evidence includes RCTs, quasi-experimental studies, and a systematic review. The relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review, which included three quasi-experimental studies, rated study quality as poor. One RCT was double-blind and sham-controlled; it found a statistically significant greater reduction in pain in the dry needling group than in the sham group but the difference was not clinically significant (i.e., it did not meet the prespecified minimally important difference). The other RCT, a single-blind trial comparing dry needling with usual care, found a significantly greater reduction in pain at the end of active treatment but not at follow-up one month later. Moreover, range of motion outcomes did not differ significantly between groups at either time point. To date, the studies have not demonstrated a statistical or a clinical benefit for dry needling. Additional RCTs, especially those with a sham-control group, would strengthen the evidence base. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have myofascial trigger points associated with temporomandibular myofascial pain who receive dry needling of trigger points, the evidence includes an RCT. The relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One double-blind, sham-controlled randomized trial was identified; it found that one week after completing the intervention, there were no statistically significant differences between groups in pain scores or function (unassisted jaw opening without pain). There was a significantly higher pain pressure threshold in the treatment group. Additional RCTs, especially those with a sham-control group, are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

Background
Myofascial Trigger Points
Myofascial pain is defined by the presence of trigger points: Discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Trigger points are associated with local ischemia and hypoxia, a significantly lowered pH, local and referred pain and altered muscle activation patterns.¹ Trigger points can be visualized by magnetic resonance imaging and elastography. The reliability of manual identification of trigger points has not been established.

Dry Needling
Dry needling refers to a procedure in which a fine needle is inserted into the skin and muscle at a site of myofascial pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The intent is to stimulate underlying myofascial trigger points, muscles, and connective tissues to manage myofascial pain. Dry needling may be performed with acupuncture needles or standard hypodermic needles but is performed without the injection of medications (e.g., anesthetics, corticosteroids). Dry needling is proposed to treat dysfunctions in skeletal muscle, fascia, and connective tissue; diminish persistent peripheral pain; and reduce impairments of body structure and function.

The physiologic basis for dry needling depends on the targeted tissue and treatment objectives. The most studied targets are trigger points.¹

Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. This local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle, and has been associated with alleviation of spontaneous electrical activity; reduction of numerous nociceptive, inflammatory, and immune system-related chemicals; and relaxation of the taut band. Deep dry needling of trigger points is believed to reduce local and referred pain, improve range of motion, and decrease trigger point irritability.¹

Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses. The physiologic basis for dry needling treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not as well described in the literature.   

Regulatory Status 
Dry needling is considered a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Policy 
Dry needling and trigger point injections for the treatment of myofascial pain are  investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

Policy Guidelines 
Please see the Codes table for details.

Rationale 
Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function, including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, two domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Dry Needling of Myofascial Trigger Points Associated with Neck and/or Shoulder Pain
Clinical Context and Therapy Purpose
The purpose of dry needling in patients who have myofascial neck and/or shoulder pain is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does dry needling improve the net health outcome in patients with myofascial neck and/or shoulder pain?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with myofascial trigger points associated with myofascial neck and/or shoulder pain. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated.

Interventions
The therapy being considered is dry needling.

Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The physiologic basis for dry needling depends on the targeted tissue and treatment objectives. Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses.

Comparators
Alternative nonpharmacologic treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch.²

Outcomes
The outcomes of interest are symptoms, functional outcomes, quality of life, and treatment-related morbidity.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
Charles et al. (2019) conducted a systematic review of different techniques for treatment of myofascial pain.³ A total of 23 RCTs of dry needling were included. Of these, 15 assessed the technique for neck or shoulder pain. The quality of evidence for dry needling in the management of myofascial pain and trigger points ranged from very low to moderate compared with control groups, sham interventions, or other treatments for changes in pain, pressure point threshold, and functional outcomes. Multiple limitations in the body of the evidence were identified, including high risk of bias, small sample sizes, unclear randomization and concealment procedures, inappropriate blinding, imbalanced baseline characteristics, lack of standardized methodologies, unreliable outcome measures, high attrition rates, unknown long-term treatment effects, lack of effective sham methods, and lack of standardized guidelines in the location of trigger points. The reviewers concluded that the evidence for dry needling was not greater than placebo.

Navarro-Santana et al. (2020) conducted a systematic review and meta-analysis of dry needling of myofascial trigger points associated with neck pain compared to sham needling, no intervention, or other physical interventions.4, A total of 28 RCTs were included. Dry needling reduced pain immediately after the intervention (mean difference [MD] in pain score, -1.53; 95% confidence interval [CI], -2.29 to -0.76) and at the short-term (up to 1 month) (MD, -2.31 ; 95% CI, -3.64 to -0.99) when compared with sham, placebo, waiting list, or other forms of dry needling, and at the short-term compared with manual therapy (MD, -0.51 ; 95% CI, -0.95 to -0.06). No differences in comparison with other physical therapy interventions were observed. An effect on pain-related disability at the short-term was found when comparing dry needling with sham, placebo, waiting list, or other form of dry needling, but not with manual therapy or other physical therapy interventions.

Navarro-Santana et al. (2020) also conducted a systematic review and meta-analysis of dry needling for shoulder pain.⁵ The meta-analysis found moderate quality evidence for a small effect (MD, -0.49 points; 95% CI, -0.84 to -0.13; standardized mean difference [SMD], -0.25; 95% CI, -0.42 to -0.09) for decreasing shoulder pain intensity, and low quality evidence for a large effect (MD, -9.99 points; 95% CI, -15.97 to -4.01; SMD, -1.14; 95% CI, -1.81 to -0.47) for reducing related disability. The effects on pain intensity were found only in the short term (up to 1 month) and did not reach the minimal clinically important difference of 1.1 points for the numerical pain rating scale (0 to 10) determined for patients with shoulder pain. Confidence intervals of the main effects of dry needling on pain intensity and related disability were wide. Additionally, the trials were heterogeneous with regard to the number and/or frequency of needling sessions and the type of comparator.

Section Summary: Neck and/or Shoulder Pain
A number of RCTs and systematic reviews of these studies have evaluated dry needling of myofascial trigger points for neck and/or shoulder pain. A systematic review of techniques for myofascial pain included 15 studies of dry needling for neck or shoulder pain published through 2017. Studies had multiple methodological limitations, and the reviewers concluded that the evidence for dry needling was not greater than placebo. In more recent systematic reviews and meta-analyses, dry needling was not associated with clinically important reductions in shoulder or neck pain when compared to other physical therapy modalities.

Dry Needling of Myofascial Trigger Points Associated With Plantar Heel Pain
Clinical Context and Therapy Purpose
The purpose of dry needling in patients who have plantar heel myofascial pain is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does dry needling improve the net health outcome in patients with plantar heel myofascial pain?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with myofascial trigger points associated with plantar heel pain. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated.

Interventions
The therapy being considered is dry needling.

Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The physiologic basis for dry needling depends on the targeted tissue and treatment objectives. Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses.

Comparators
Alternative nonpharmacologic treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch.²

Outcomes
The outcomes of interest are symptoms, functional outcomes, quality of life, and treatment-related morbidity.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Review
Llurda-Almuzara et al. (2021) published a systematic review of 6 randomized trials (N = 395) evaluating dry needling for the treatment of plantar fasciitis (Tables 1 to 3).⁶ None of the included trials were double-blind and, although the authors did find some positive effects of dry needling, the heterogeneity, lack of blinding, and small number of patients in the trials limits applicability.

Table 1. Trials Included in Systematic Review

Table 2. Systematic Review Characteristics

RCT: randomized controlled trial.

Table 3. Systematic Review Results

CI: confidence interval; SMD: standardized mean difference.

Section Summary: Plantar Heel Pain
The evidence base consists of a systematic review of RCTs. The authors included six randomized trials enrolling 395 patients and found no overall difference in pain intensity in those treated with dry needling compared with active control, placebo, or no intervention. However, pain intensity after at least three sessions, long-term pain intensity, and pain-related disability were improved. The systematic review rated the quality of the studies it assessed as low to moderate. The evidence is limited by small patient populations and lack of blinding; therefore, additional RCTs are needed to strengthen the evidence base.

Dry Needling of Myofascial Trigger Points Associated With Temporomandibular Pain
Clinical Context and Therapy Purpose
The purpose of dry needling in patients who have temporomandibular myofascial pain is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does dry needling improve the net health outcome in patients with temporomandibular myofascial pain?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with myofascial trigger points associated with temporomandibular myofascial pain. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated.

Interventions
The therapy being considered is dry needling.

Dry needling refers to a procedure whereby a fine needle is inserted into the trigger point to induce a twitch response and relieve the pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The physiologic basis for dry needling depends on the targeted tissue and treatment objectives. Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses.

Comparators
Alternative nonpharmacologic treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch.²

Outcomes
The outcomes of interest are symptoms, functional outcomes, quality of life, and treatment-related morbidity.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Randomized Controlled Trials
A double-blind, sham-controlled trial of dry needling for the treatment of temporomandibular myofascial pain was reported by Diracoglu et al. (2012).¹³ Patients (N = 52) with symptoms for at least six weeks with two or more myofascial trigger points in the temporomandibular muscles were included in the trial. Trigger points were stimulated once weekly over 3 weeks. The sham condition involved dry needling in areas away from the trigger points. Patients were evaluated one week after the last needling. At follow-up, there was no significant difference between groups in pain scores assessed by a 10-point visual analog scale. Mean visual analog scale scores were 3.88 in the treatment group and 3.80 in the control group (p = .478). Also, the difference in unassisted jaw opening without pain did not differ significantly between the treatment group (40.1 mm) and the control group (39.6 mm; p = .411). The mean pain pressure threshold was significantly higher in the treatment group (3.21 kg/cm2) than in the control group (2.75 kg/cm2; p < .001).

Section Summary: Temporomandibular Myofascial Pain
One RCT evaluating dry needling for the treatment of temporomandibular myofascial pain was identified; this trial was double-blind and sham-controlled. One week after completing the intervention, there were no statistically significant differences between groups in pain scores or function (unassisted jaw opening without pain). There was a significantly higher pain pressure threshold in the treatment group. This single RCT does not provide sufficient evidence on which to draw conclusions about the impact of dry needling on health outcomes in patients with temporomandibular myofascial pain.

Adverse Events
A prospective survey (2014) of 39 physical therapists, providing 7,629 dry needling treatments, reported 1,463 (19.18%) mild adverse events (bruising, bleeding, pain) and no serious adverse events.¹⁴

Summary of Evidence
For individuals who have myofascial trigger points associated with neck and/or shoulder pain who receive dry needling of trigger points, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of techniques to treat myofascial pain included 15 studies of dry needling for neck or shoulder pain published through 2017. Studies had multiple methodological limitations, and the reviewers concluded that the evidence for dry needling was not greater than placebo. In more recent systematic reviews and meta-analyses, dry needling was not associated with clinically important reductions in shoulder or neck pain when compared to other physical therapy modalities. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myofascial trigger points associated with plantar heel pain who receive dry needling of trigger points, the evidence includes a systematic review of randomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic review included six randomized trials enrolling 395 patients and found no overall difference in pain intensity in those treated with dry needling compared with active control, placebo, or no intervention. However, pain intensity after at least three sessions, long-term pain intensity, and pain-related disability were improved. The systematic review rated the evidence as low to moderate. The evidence for dry needling in patients with plantar heel pain is limited by small patient populations and lack of blinding; therefore, additional RCTs are needed to strengthen the evidence base. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have myofascial trigger points associated with temporomandibular myofascial pain who receive dry needling of trigger points, the evidence includes an RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One double-blind, sham-controlled randomized trial was identified; it found that one week after completing the intervention, there were no statistically significant differences between groups in pain scores or function (unassisted jaw opening without pain). There was a significantly higher pain pressure threshold in the treatment group. Additional RCTs, especially those with a sham-control group, are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in Supplemental Information if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Academy of Orthopaedic Physical Therapists
In 2009, the American Academy of Orthopaedic Physical Therapists issued a statement that dry needling fell within the scope of physical therapist practice.15, In support of this position, the Academy stated that “dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system …. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.”

American Physical Therapy Association
In 2012, an educational resource paper by the American Physical Therapy Association defined dry needling as “an invasive technique used by physical therapists (where allowed by state law) to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points.”¹⁶

U.S. Preventive Services Task Force Recommendations
Not applicable

Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 4.

Table 4. Summary of Key Trials

NCT: national clinical trial.

References  

1. American Physical Therapy Association (APTA). Dry Needling. n.d.; https://www.apta.org/patient-care/interventions/dry-needling. Accessed February 11, 2022.
2. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. Feb 15 2002; 65(4): 653-60. PMID 11871683
3. Charles D, Hudgins T, MacNaughton J, et al. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points. J Bodyw Mov Ther. Jul 2019; 23(3): 539-546. PMID 31563367
4. Navarro-Santana MJ, Sanchez-Infante J, Fernandez-de-Las-Penas C, et al. Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis. J Clin Med. Oct 14 2020; 9(10). PMID 33066556
5. Navarro-Santana MJ, Gomez-Chiguano GF, Cleland JA, et al. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Phys Ther. Feb 04 2021; 101(2). PMID 33340405
6. Llurda-Almuzara L, Labata-Lezaun N, Meca-Rivera T, et al. Is Dry Needling Effective for the Management of Plantar Heel Pain or Plantar Fasciitis? An Updated Systematic Review and Meta-Analysis. Pain Med. Jul 25 2021; 22(7): 1630-1641. PMID 33760098
7. Bagcier F, Yilmaz N. The Impact of Extracorporeal Shock Wave Therapy and Dry Needling Combination on Pain and Functionality in the Patients Diagnosed with Plantar Fasciitis. J Foot Ankle Surg. Jul 2020; 59(4): 689-693. PMID 32340838
8. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. Aug 2014; 94(8): 1083-94. PMID 24700136
9. Eftekharsadat B, Babaei-Ghazani A, Zeinolabedinzadeh V. Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Med J Islam Repub Iran. 2016; 30: 401. PMID 27683642
10. Rahbar M, Kargar A, Eslamian F, Dolatkhah N. Comparing the efficacy of dry needling and extracorporeal shock wave therapy in treatment of plantar fasciitis. J Mazandaran Univ Med Sci. 2018;28(164):53-62.
11. Rastegar S, Baradaran Mahdavi S, Hoseinzadeh B, et al. Comparison of dry needling and steroid injection in the treatment of plantar fasciitis: a single-blind randomized clinical trial. Int Orthop. Jan 2018; 42(1): 109-116. PMID 29119296
12. Uygur E, Aktas B, Eceviz E, et al. Preliminary Report on the Role of Dry Needling Versus Corticosteroid Injection, an Effective Treatment Method for Plantar Fasciitis: A Randomized Controlled Trial. J Foot Ankle Surg. Mar 2019; 58(2): 301-305. PMID 30850099
13. Diracoglu D, Vural M, Karan A, et al. Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012; 25(4): 285-90. PMID 23220812
14. Brady S, McEvoy J, Dommerholt J, et al. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Man Manip Ther. Aug 2014; 22(3): 134-40. PMID 25125935
15. American Academy of Orthopaedic Physical Therapists. AAOMPT position statement on dry needling. 2009; http://aaompt.org/Main/About_Us/Position_Statements/Main/About_Us/Position_Statements.aspx?hkey=03f5a33 3-f28d-4715-b355-cb25fa9bac2c. Accessed February 11, 2022.
16. American Physical Therapy Association (APTA). Physical Therapists and the Performance of Dry Needling. 2012; https://www.mptalliance.com/wp-content/uploads/2015/12/APTA-PTs-and-Dry-Needling-Resource-Paper.pdf. Accessed February 11, 2022.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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