Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Low-Level Laser Therapy
Policy #:MA07.036c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Low-level laser therapy is considered medically necessary, and, therefore, covered for prevention of oral mucositis in individuals who are undergoing cancer treatment that is associated with an increased risk of oral mucositis, for example, chemotherapy and/or radiotherapy and/or hematopoietic stem cell transplantation.

EXPERIMENTAL/INVESTIGATIONAL

Low-level laser therapy (LLLT) for all other conditions and LLLT with dynamic photonic and thermokinetic energy is considered experimental/investigational and, therefore, not covered, because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. This includes, but is not limited to, when low-level laser therapy is used for the following conditions:
  • Carpal tunnel syndrome
  • Neck pain
  • Subacromial impingement
  • Adhesive capsulitis
  • Temporomandibular joint pain
  • Low back pain
  • Osteoarthritis
  • Heel pain (i.e., Achilles tendinopathy, plantar fasciitis)
  • Rheumatoid arthritis
  • Bell's palsy
  • Fibromyalgia
  • Wound healing
  • Lymphedema
  • General joint pain
  • Toxic joint syndrome
  • Psoriatic arthritis
  • Fibromyalgia
  • Knee pain
  • Plica syndrome
  • Osgood-schlatter
  • Patellofemoral syndrome
  • Gout
  • Lupus
  • Plantar fasciitis
  • Tennis elbow
  • Occipital myospastic headaches
  • Tension headaches
  • Muscular headaches
  • Rotator cuff injuries
  • Major depressive disorder
  • Alzheimer's disease

BILLING REQUIREMENTS

Using the Current Procedural Terminology (CPT) procedure code 97026 (infrared therapy) or any other code to report low-level laser therapy is a misrepresentation of the actual service rendered. These services are subject to post-payment review and audit procedures.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Policy Guidelines

There is no Medicare coverage criteria addressing this service; therefore, the Company policy is applicable.
The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, low-level laser therapy when used for the prevention of oral mucositis, is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are experimental/investigational are excluded the Company’s Medicare Advantage products. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous lasers approved by the FDA for low-level laser therapy.

Description

Low-level laser therapy refers to the use of polarized red-beam or near-infrared light to provide pain relief for various acute and chronic conditions. In contrast to more powerful surgical lasers, low-level laser light has low power, usually 5-500 milliwatts with wavelengths of 600-1000 nm. When applied to the skin, cold laser therapy does not burn and produces little or no sensation. While the exact mechanism of its effect is unknown, it is hypothesized that the cold laser light energy penetrates into tissues stimulating the cellular and extracellular systems (eg, neurologic, vascular, immune, lymphatic) increasing serotonin levels with resultant pain relief and/or accelerated healing.

Smart Laser (Willow Curve) is newly developed advanced medical technology designed to relieve joint pain with thermal and photonic energy residing in the category of low-level laser therapy. The photonic and thermal kinetic energies stimulate 15 bio-physiological processes for treating the joint and surrounding tissues by dilating blood vessels and increasing lymphatic flow to reduce swelling, slowing nerve response time and releasing endorphins reducing the perception of pain, blocking specific pain receptors to promote pain relief and detoxifying by removing toxic debris from the joints increasing the circulation. However, no published peer-reviewed literature was identified to support the use of low level laser therapy with dynamic photonic and thermokinetic energy.

Low level laser therapy also known as transcranial photobiomodulation therapy is a modality using low power lasers and light-emitting diodes in the far-red to near-infrared optical region to penetrate brain tissues and enhance ATP biosynthesis, regulate mitochondrial homeostasis, enhance serotonin and dopamine levels in the brain and facilitate neurogenesis and/or neuroplasticity proposed for the treatment of depression and Alzheimer’s disease. Preliminary clinical study evidence explores the potential use of low level laser therapy for major depressive disorder; however, future studies are needed to clarify ideal stimulation parameters and the overall efficacy, effectiveness and safety of this treatment. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have increased risk of oral mucositis due to some cancer treatments (e.g., chemotherapy, radiotherapy) and/or hematopoietic stem cell transplantation includes randomized controlled trials (RCTs) and systematic reviews of RCTs. Relevant outcomes are symptoms, morbid events, quality of life, and treatment-related morbidity. Studies included patients undergoing various cancer chemotherapy regimens or hematopoietic stem cell transplantation. A recent systematic review of RCTs on low-level laser for prevention of oral mucositis included 18 RCTs, generally considered at low risk of bias, and found statistically significantly better outcomes with low-level laser therapy than control conditions on primary and secondary outcomes. In addition, three double-blind RCTs published in 2015 found significantly better outcomes in individuals undergoing low-level laser therapy than undergoing sham treatment prior to or during cancer treatment. The evidence is sufficient to determine qualitatively that the technology results in a meaningful improvement in the net health outcome.

The evidence for low-level laser therapy in individuals who have orthopedic pain (i.e., neck pain, osteoarthritis knee pain, low back pain, carpal tunnel syndrome) includes RCTs and, for some indications, systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Findings of the RCTs were mixed and had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have shoulder conditions, heel pain, or temporomandibular joint pain includes RCTs and, for some indications, systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Findings of the RCTs were mixed and had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have bone, ligament, and joint conditions (e.g., rheumatoid arthritis, fibromyalgia) includes RCTs and, for some indications, systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Findings of the RCTs were mixed and had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have Bell's palsy includes an RCT. Relevant outcomes are change in disease status, functional outcomes, quality of life, and treatment-related morbidity. Bell's palsy may completely resolve within months and, thus, it is difficult to determine improvements from laser therapy over the natural resolution of the illness. The available RCT did not include a sham treatment; low-level laser therapy was superior to exercise only in this study. Sham-controlled studies are needed as well as additional studies comparing low-level laser therapy with alternative Bell's palsy treatments. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have lymphedema includes RCTs, observational studies, and systematic reviews. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment related morbidity. Systematic reviews of RCTs and observational studies found methodologic flaws in the available studies and have not consistently found better outcomes in individuals receiving low-level laser therapy than in individuals receiving a control condition treatment. The evidence is insufficient to determine the effects of the technology on health outcome.

The evidence for low-level laser therapy in individuals who have chronic wounds includes RCTs and systematic reviews. Relevant outcomes are symptoms, change in disease status, and treatment-related morbidity. The few existing RCTs tend to have small sample sizes and risk of bias. The evidence is insufficient to determine the effects of the technology on health outcome.


References

Abrisham SM, Kermani-Alghoraishi M, Ghahramani R, et al. Additive effects of low-level laser therapy with exercise on subacromial syndrome: a randomized, double-blind, controlled trial. Clin Rheumatol. 2011;30(10):1341-1346.

Alayat MS, Elsodany AM, El Fiky AA. Efficacy of high and low level laser therapy in the treatment of Bell's palsy: a randomized double blind placebo-controlled trial. Lasers Med Sci. 2014;29(1):335-342.

Ash C, Dubec M, Donne K, et al. Effect of wavelength and beam width on penetration in light -tissue interaction using computational methods. Lasers Med Sci. 2017; 32(8):1909-1918.

American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guideline on the treatment of carpal tunnel syndrome. [AAOS Web site]. 2008. Available at:https://aaos.org/quality/quality-programs/upper-extremity-programs/carpal-tunnel-syndrome/. Accessed February 25, 2020.

Bal A, Eksioglu E, Gurcay E, et al. Low-level laser therapy in subacromial impingement syndrome. Photomed Laser Surg. 2009;27(1):31-36.

Barbosa RI, Fonseca MC, Rodrigues EK, et al. Efficacy of low-level laser therapy associated to orthoses for patients with carpal tunnel syndrome: A randomized single-blinded controlled trial. J Back Musculoskelet Rehabil. Sep 25 2015.

Bjordal JM, Johnson MI, Lopes-Martins RA, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51.

Blue Cross and Blue Shield Technology Evaluation Center (TEC). Low-level laser therapy for carpal tunnel syndrome and chronic neck pain. TEC Assessment. Nov 2010;Volume 25, Tab 4.

Brosseau L, Robinson V, Wells G, et al. Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2005(4):CD002049.

Caldieraro MA, Cassano P. Transcranial and systemic photobiomodulation for major depressive disorder: A systemic review of efficacy, tolerability and biological mechanisms. J Affect Disord. 2019; 243:262-273.

Calis HT, Berberoglu N, Calis M. Are ultrasound, laser and exercise superior to each other in the treatment of subacromial impingement syndrome? A randomized clinical trial. Eur J Phys Rehabil Med. 2011;47(3):375-380.

Carcia CR, Martin RL, Houck J, et al. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis. J Orthop Sports Phys Ther. 2010;40(9):A1-26.

Carrasco TG, Guerisoli LD, Guerisoli DM, et al. Evaluation of low intensity laser therapy in myofascial pain syndrome. Cranio. 2009;27(4):243-247.

Cassano P, Petrie SR, Mischoulon D, et al. Transcranial photobiomodulation for the treatment of major depressive disorder, The ELATED-2 pilot trial. Photomedicine and Laser Surgery. 2018; 20(20):1-13.

Chang J, Ren Y, Wang R, et al. Transcranial low-level laser therapy for depression and alzheimer's disease. JNeuropsychiatry. 2018; 8(2):477-483.

Chang WD, Lee CL, Lin HY, et al. A meta-analysis of clinical effects of low-level laser therapy on temporomandibular joint pain. J Phys Ther Sci. 2014;26(8):1297-1300.

Chang WD, Wu JH, Jiang JA, et al. Carpal tunnel syndrome treated with a diode laser: a controlled treatment of the transverse carpal ligament. Photomed Laser Surg. 2008;26(6):551-557.

Chen C, Hou WH, Chan ES, et al. Phototherapy for treating pressure ulcers. Cochrane Database Syst Rev. 2014;7:CD009224.

Chen J, Huang Z, Ge M, et al. Efficacy of low-level laser therapy in the treatment of TMDs: a meta-analysis of 14 randomised controlled trials. J Oral Rehabil. 2015;42(4):291-299.

Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34(10):1066-1077.

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.

Chow RT, Heller GZ, Barnsley L. The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain. 2006;124(1-2):201-210.

da Cunha LA, Firoozmand LM, da Silva AP, et al. Efficacy of low-level laser therapy in the treatment of temporomandibular disorder. Int Dent J. 2008;58(4):213-217.

Doeuk C, Hersant B, Bosc R, et al. Current indications for low level laser treatment in maxillofacial surgery: a review. Br J Oral Maxillofac Surg. 2015;53(4):309-315.

Dogan SK, Ay S, Evcik D. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized placebo controlled double-blind prospective study. Clinics (Sao Paulo). 2010;65(10):1019-1022.

Ekim A, Armagan O, Tascioglu F, et al. Effect of low level laser therapy in rheumatoid arthritis patients with carpal tunnel syndrome. Swiss Med Wkly. 2007;137(23-24):347-352.

Emshoff R, Bosch R, Pumpel E, et al. Low-level laser therapy for treatment of temporomandibular joint pain: a double-blind and placebo-controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(4):452-456.

Evcik D, Kavuncu V, Cakir T, et al. Laser therapy in the treatment of carpal tunnel syndrome: a randomized controlled trial. Photomed Laser Surg. 2007;25(1):34-39.

Ferreira B, da Motta Silveira FM, de Orange FA. Low-level laser therapy prevents severe oral mucositis in patients submitted to hematopoietic stem cell transplantation: a randomized clinical trial. Support Care Cancer. 2016;24(3):1035-1042.

Figueiredo AL, Lins L, Cattony AC, et al. Laser therapy in the control of oral mucositis: A meta-analysis. Rev Assoc Med Bras. Oct 9, 2013.

Fikackova H, Dostalova T, Navratil L, et al. Effectiveness of low-level laser therapy in temporomandibular joint disorders: a placebo-controlled study. Photomed Laser Surg. 2007;25(4):297-303.

Gautam AP, Fernandes DJ, Vidyasagar MS, et al. Low level laser therapy against radiation induced oral mucositis in elderly head and neck cancer patients-a randomized placebo controlled trial. J Photochem Photobiol B. 2015;144:51-56.

Gautam AP, Fernandes DJ, Vidyasagar MS, et al. Effect of low-level laser therapy on patient reported measures of oral mucositis and quality of life in head and neck cancer patients receiving chemoradiotherapy--a randomized controlled trial. Support Care Cancer. 2013;21(5):1421-1428.

Gautam AP, Fernandes DJ, Vidyasagar MS, et al. Low Level Helium Neon Laser therapy for chemoradiotherapy induced oral mucositis in oral cancer patients - A randomized controlled trial. Oral Oncol. 2012;48(9):893-897.

Gautam AP, Fernandes DJ, Vidyasagar MS, et al. Low level laser therapy for concurrent chemoradiotherapy induced oral mucositis in head and neck cancer patients - A triple blinded randomized controlled trial. Radiother Oncol. 2012;104(3):349-354.

Gross AR, Dziengo S, Boers O, et al. Low level laser therapy (LLLT) for neck pain: a systematic review and meta-regression. Open Orthop J. 2013;7:396-419.

Huang Z, Chen J, Ma J, et al. Effectiveness of low-level laser therapy in patients with knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2015;23(9):1437-1444.

Huang Z, Ma J, Chen J, et al. The effectiveness of low-level laser therapy for nonspecific chronic low back pain: a systematic review and meta-analysis. Arthritis Res Ther. 2015;17:360.

Irvine J, Chong SL, Amirjani N, et al. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve. 2004;30(2):182-187.

Kiritsi O, Tsitas K, Malliaropoulos N, et al. Ultrasonographic evaluation of plantar fasciitis after low-level laser therapy: results of a double-blind, randomized, placebo-controlled trial. Lasers Med Sci. 2010;25(2):275-281.

Konstantinovic LM, Kanjuh ZM, Milovanovic AN, et al. Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomed Laser Surg. 2010;28(4):553-560.

Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120(10):1453-1461.

Macias DM, Coughlin MJ, Zang K, et al. Low-Level Laser Therapy at 635 nm for Treatment of Chronic Plantar Fasciitis: A Placebo-Controlled, Randomized Study. J Foot Ankle Surg. 2015;54(5):768-772.

Mandel A, Hamblin MR. A renaissance in low-level laser (light) therapy-LLLT. Phototonics And Lasers In Medicine 1. 2012:4:231-243.

Marini I, Gatto MR, Bonetti GA. Effects of superpulsed low-level laser therapy on temporomandibular joint pain. Clin J Pain. 2010;26(7):611-616.

Marovino T, Majewski M. Pain therapy options for the home. A patient-based outcome review of at-home pain management devices, including the Willow Curve, Quell, and VibraCool. Practical Pain Management. 2019; 19(1): 56-59.

Matsutani LA, Marques AP, Ferreira EA, et al. Effectiveness of muscle stretching exercises with and without laser therapy at tender points for patients with fibromyalgia. Clin Exp Rheumatol. 2007;25(3):410-415.

Meireles SM, Jones A, Jennings F, et al. Assessment of the effectiveness of low-level laser therapy on the hands of patients with rheumatoid arthritis: a randomized double-blind controlled trial. Clin Rheumatol. 2010;29(5):501-509.

Multinational Association of Supportive Care in Cancer (MASCC). Clinical Practice guidelines for the management of mucositis secondary to cancer therapy. [MASCC Web site]. 05/15/2014. Available at: http://www.mascc.org/assets/Guidelines-Tools/mascc%20isoo%20mucositis%20guidelines%20paper%206jun2014.pdf. Accessed June 21, 2019

National Comprehensive Cancer Network (NCCN). Head and Neck Cancers.V1.2019. [NCCN Web site]. 02/12/2020. Available at: http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Accessed February 25, 2020.

Oberoi S, Zamperlini-Netto G, Beyene J, et al. Effect of prophylactic low level laser therapy on oral mucositis: a systematic review and meta-analysis. PLoS One. 2014;9(9):e107418.

Oton-Leite AF, Silva GB, Morais MO, et al. Effect of low-level laser therapy on chemoradiotherapy-induced oral mucositis and salivary inflammatory mediators in head and neck cancer patients. Lasers Surg Med. 2015;47(4):296-305.

Omar MT, Shaheen AA, Zafar H. A systematic review of the effect of low-level laser therapy in the management of breast cancer-related lymphedema. Support Care Cancer. 2012;20:2977-2984.

Omar MTA, Ebid AA, El Morsy AM. Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. J Surg Res. 2011;165(1):82-90.

Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;10:CD011324.

Petrucci A, Sgolastra F, Gatto R, et al. Effectiveness of low-level laser therapy in temporomandibular disorders: a systematic review and meta-analysis. J Orofac Pain. 2011;25(4):298-307.

Ruaro JA, Frez AR, Ruaro MB, et al. Low-level laser therapy to treat fibromyalgia. Lasers Med Sci. 2014;29(6):1815-1819.

Salehpour F, Rasta SH. The potential of transcranial photobiomodulation therapy for treatment of major depressive disorder. Rev Neurosci. 2017;28(4):441-453.

Samson D, Lefevre F, Aronson N. Wound-healing technologies: low-level laser and vacuum-assisted closure. Evid Rep Technol Assess (Summ). 2004(111):1-6.

Savigny P, Kuntze S, Watson P, et al. Low back pain: early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care and Royal College of General Practitioners. [NICE Web site]. 2009. Available at: https://www.nice.org.uk/guidance/cg88/documents/low-back-pain-draft-full-guideline2 . Accessed February 25, 2020.

Schubert MM, Eduardo FP, Guthrie KA, et al. A phase III randomized double-blind placebo-controlled clinical trial to determine the efficacy of low level laser therapy for the prevention of oral mucositis in patients undergoing hematopoietic cell transplantation. Support Care Cancer. 2007;15(10):1145-1154.

Shapiro RS. The scientific aspects of smart-level technology. Chiropractic News Research and Marketing. [meyerdc Web site]. 01/16/2019. Available at: http://news.meyerdc.com/chiropractors/scientific-aspects-smart-laser-technology. Accessed February 25, 2020.

Smoot B, Chiavola-Larson L, Lee J, et al. Effect of low-level laser therapy on pain and swelling in women with breast cancer-related lymphedema: a systematic review and meta-analysis. J Cancer Surviv. 2015;9(2):287-304.

Stergioulas A. Low-power laser treatment in patients with frozen shoulder: preliminary results. Photomed Laser Surg. 2008;26(2):99-105.

Stergioulas A, Stergioula M, Aarskog R, et al. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008;36(5):881-887.

Tascioglu F, Degirmenci NA, Ozkan S, et al. Low-level laser in the treatment of carpal tunnel syndrome: clinical, electrophysiological, and ultrasonographical evaluation. Rheumatol Int. 2012;32(2):409-415.

Tumilty S, McDonough S, Hurley DA, et al. Clinical effectiveness of low-level laser therapy as an adjunct to eccentric exercise for the treatment of Achilles' tendinopathy: a randomized controlled trial. Arch Phys MedRehabil. 2012;93(5):733-739.

Venezian GC, da Silva MA, Mazzetto RG, et al. Low level laser effects on pain to palpation and electromyographic activity in TMD patients: a double-blind, randomized, placebo-controlled study. Cranio. 2010;28(2):84-91.

Willow Curve. The Official Willow Curve Smart Therapy for Joint Pain. Available at: www.willowcurve.com. Accessed: February 25, 2020.

Xu Z, Guo X, Yang Y, et al. Low-level laser irradiation improves depression-like behaviors in mice. Mol Neurobiol. 2017; 54(6):4551-4559.

Yeldan I, Cetin E, Ozdincler AR. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Disabil Rehabil. 2009;31(11):935-940.

Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev. 2008(2):CD005107.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

EXPERIMENTAL/INVESTIGATIONAL


0552T



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

LOW-LEVEL LASER THERAPY (S8948) IS MEDICALLY NECESSARY IN INDIVIDUALS WHO ARE UNDERGOING CANCER TREATMENT

Z51.0 Encounter for antineoplastic radiation therapy

Z51.11 Encounter for antineoplastic chemotherapy

Z92.21 Personal history of antineoplastic chemotherapy

Z92.3 Personal history of irradiation

Z94.84 Stem cells transplant status



HCPCS Level II Code Number(s)



S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes



Revenue Code Number(s)

N/A

Coding and Billing Requirements

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

BILLING REQUIREMENTS

Low-level laser therapy is described by Healthcare Common Procedure Coding System (HCPCS) code S8948 and should not be billed with any other code.

Using the Current Procedural Terminology (CPT) procedure code 97026 (infrared therapy) or any other code to report low-level laser therapy is a misrepresentation of the actual service rendered. These services are subject to post-payment review and audit procedures.





Policy History

MA07.036c
04/08/2020The policy has been reviewed and reissued to communicate the Company's continuing position on Low-Level Laser Therapy (LLLT).


MA07.036c
09/30/2019
This version of the policy will become effective 09/30/2019.

The policy has been updated to communicate the Company's experimental/investigational position for low-level laser therapy with dynamic photonic and thermokinetic energy.

The following CPT code has been added to the policy: 0552T.

The following ICD-10 diagnosis codes have been added to the policy:
Z51.0, Z51.11, Z92.21, Z92.3, Z94.84




MA07.036b
03/13/2019 The policy has been reviewed and reissued to communicate the Company's continuing position on Low-Level Laser Therapy (LLLT).
03/14/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Low-Level Laser Therapy.
03/01/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on cold laser therapy.
10/14/2016This policy will become effective 10/14/2016.

A new covered indication for the prevention of oral mucositis was added to the policy section.

New language was added to the description section.

The references were updated accordingly.

MA07.036a
04/08/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on cold laser therapy.

MA07.036
01/01/2015This is a new policy.




Version Effective Date: 09/30/2019
Version Issued Date: 09/30/2019
Version Reissued Date: 04/08/2020