CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Low-Level Laser Therapy (LLLT) — Coverage Criteria

This policy governs coverage and medical necessity determinations for low-level laser therapy (LLLT)/photobiomodulation for Medicare Advantage and commercial members, specifying covered indication(s) and not medically necessary uses.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLow-Level Laser Therapy (LLLT) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 11, 2022

Next Review DateN/A

Key ActionUse LLLT only for prevention of oral mucositis in patients undergoing cancer treatment at increased risk; other indications are not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Indications explicitly covered

>12Not-covered indications listed

600-1000 nmWavelength described

2Procedure codes listed

26+References

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Coverage Criteria for Low-Level Laser Therapy (LLLT)

Covered Indication — Prevention of Oral Mucositis

Covered when ALL of the following are met

Prevention of oral mucositis: Patient is undergoing cancer treatment associated with increased risk of oral mucositis (including chemotherapy and/or radiotherapy and/or hematopoietic stem cell transplantation) and low-level laser therapy (LLLT) is used for prevention of oral mucositis.

Policy states LLLT is covered for prevention of oral mucositis in these patients.

Not Medically Necessary / Not Covered Indications

Not medically necessary / Not covered for other indications

Other indications: Use of LLLT for other conditions (including but not limited to carpal tunnel syndrome; neck pain; subacromial impingement; adhesive capsulitis; temporomandibular joint pain; low back pain; osteoarthritic knee pain; heel pain (eg, Achilles tendinopathy, plantar fasciitis); rheumatoid arthritis; Bell palsy; fibromyalgia; wound healing or chronic non-healing wounds; and lymphedema) is considered not medically necessary or not covered due to insufficient evidence.

Policy lists examples of excluded/not medically necessary indications.

Benefits for Low-Level Laser Therapy (LLLT) may vary by group and contract. Refer to the member's specific Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to confirm whether LLLT services are covered or excluded under that plan.

If a service is determined to be not medically necessary or is a non-covered benefit according to the member's plan documents (subscriber agreement, member certificate, or employer agreement), it is excluded from coverage. For member-specific questions, contact the provider call center; those plan documents supersede this policy.

LLLT is covered only for the prevention of oral mucositis in patients undergoing cancer treatment associated with increased risk of oral mucositis (including chemotherapy and/or radiotherapy and/or hematopoietic stem cell transplantation). Use of LLLT for other indications is not covered / not medically necessary. Examples of non-covered indications include, but are not limited to: carpal tunnel syndrome, neck pain, subacromial impingement, adhesive capsulitis, temporomandibular joint pain, low back pain, osteoarthritic knee pain, heel pain (eg, Achilles tendinopathy, plantar fasciitis), rheumatoid arthritis, Bell palsy, fibromyalgia, wound healing, and lymphedema.

Services that are determined to be not medically necessary may be denied and are not covered under the member's benefits. Providers may not bill members for such services unless the member was informed in advance and provided written agreement to accept financial responsibility.

Procedure and Diagnosis Codes

Covered procedure codesCPT | HCPCSCovered

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
S8948	Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

Covered procedure codes (plain list)mixedCovered

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
S8948	Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

Applicable ICD-10 Diagnosis CodesICD-10

C00-D49	Neoplasms (ICD-10 range) — used for cancer-related diagnoses
K12.30-K12.39	Oral mucositis diagnosis codes

Provider Responsibilities and Billing Guidance

Prior Authorization

Prior authorization is not applicable for this policy. Providers should still verify member-specific benefits and eligibility before rendering services.

Prior authorization: Not applicable for this policy

Note

Prior Authorization / Benefits Verification

For member-specific benefits and eligibility, providers must contact the Blue Cross Blue Shield - Rhode Island provider call center. Coverage and benefits are determined by the member's subscriber agreement, member certificate, and/or employer agreement; those documents supersede this policy.

Contact provider services / provider call center for eligibility and benefits verification
Benefits and coverage determined by subscriber agreement/member certificate/employer agreement

Background on Low-Level Laser Therapy

Low-level laser therapy (LLLT), also referred to as photobiomodulation, uses red-beam or near-infrared lasers with wavelengths between 600 and 1000 nm and low power settings (described in the literature as approximately 5–500 mW). These devices are intended to produce photobiostimulative effects without heating or burning the skin. The exact mechanism is uncertain but is hypothesized to improve cellular repair and to modulate immune, lymphatic, and vascular responses, which has prompted evaluation of LLLT across a range of clinical conditions.

Definitions

Oral mucositis — definition and typical onset after cancer therapy

DefinitionInflammation of the oral mucosa typically manifesting as erythema or ulcerations that appear 7 to 10 days after initiation of high-dose cancer therapy.

Common clinical consequencesCan cause significant pain, increased risk of systemic infection, dependence on total parenteral nutrition, and use of narcotic analgesics.

Typical onset after therapyUsually appears 7–10 days after starting high-dose cancer treatment.

Low-level laser therapy (photobiomodulation) — definition and therapeutic context

DefinitionLow-level laser therapy (LLLT), also called photobiomodulation, uses red-beam or near-infrared lasers with wavelengths between 600 and 1000 nm and low power (described in the policy as 5–500 mW) to produce photobiostimulative effects without burning the skin.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLow-Level Laser Therapy (LLLT) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 11, 2022

Next Review DateN/A

Key ActionUse LLLT only for prevention of oral mucositis in patients undergoing cancer treatment at increased risk; other indications are not covered.

SourceLink

On This Page

Denial Risk

Member Financial Responsibility and Denial Risk

If services are determined to be not medically necessary or are non-covered benefits under the member's plan, the claim may be denied. Providers may not bill members for denied services unless the member was informed in advance and provided written agreement to pay out-of-pocket. Refer to participation and provider agreements for additional billing rules.

Denied or non-covered services: Do not bill member unless written advance agreement obtained
Member financial responsibility determined by subscriber/employer agreement

Billing Rule

Billing Diagnosis Pairing

Submit covered LLLT procedure codes with an appropriate ICD-10 diagnosis from the covered ranges when applicable.

When filing covered codes (eg, 0552T, S8948), include ICD-10 CM diagnosis codes in the ranges C00-D49 or K12.30-K12.39 as applicable

Denial Risk

Denial Risk for Non-Mucositis Indications

Claims for low-level laser therapy (LLLT) provided for indications other than prevention of oral mucositis related to cancer treatment may be denied as not covered or not medically necessary.

Denial risk for non-mucositis indications (eg, carpal tunnel syndrome, neck pain, osteoarthritic knee pain, wound healing, lymphedema, etc.)

Note

Eligibility and Benefits Verification

Providers must call the provider call center to verify eligibility and rely on the subscriber agreement for member-specific benefit determinations. Coverage limitations and member cost-sharing follow the member's plan documents.

Providers must verify eligibility and benefits through the provider call center
Rely on subscriber agreement for member-specific coverage and cost-sharing

Mechanism and effects

Proposed to penetrate into tissues with low absorption by skin and to promote cellular repair and modulation of immune, lymphatic, and vascular systems; exact mechanism is unknown.

Clinical contextA noninvasive therapeutic modality evaluated in randomized controlled trials and systematic reviews for conditions including soft tissue injuries, myofascial pain, tendinopathies, nerve injuries, joint pain, and lymphedema—and studied in multiple RCTs/reviews (see references).

Device parametersWavelength range: 600–1000 nm; power range: 5–500 mW (policy contrasts this with surgical lasers of ~300 W).