Currentblue cross blue shield - south dakotaPolicy 02.01.82

02.01.82 High Intensity Laser Therapy

Defines Wellmark/Blue Cross Blue Shield - South Dakota coverage position for high-intensity (Class IV) laser therapy for chronic musculoskeletal pain, Bell's palsy, and other indications, summarizes evidence, regulatory status, coding guidance, and policy history.

Policy Summary

Payerblue cross blue shield - south dakota

Policy02.01.82 High Intensity Laser Therapy

Policy CodePolicy 02.01.82

Change TypeRevised (moved content) & Renewed

Effective DateAug 1, 2024

Next Review Date

Key ActionReport HILT services using appropriate unlisted CPT codes (e.g., 17999, 97039, 97139, 99199) and specify device and procedure details as required; note HILT is investigational for chronic musculoskeletal pain, Bell's palsy, and other indications and claims may be denied.

SourceLink

POLICY UPDATE CHANGES

Content regarding 'High Intensity Laser Therapy' moved from medical policy 02.01.14 to 02.01.82 (August 2024).

Policy renewed at annual review (August 2025).

3Indications listed as investigational (chronic musculoskeletal pain, Bell's palsy, other)

4CPT/Unlisted codes listed

2024-08Policy effective date (YYYY-MM)

numerousSystematic reviews/meta-analyses summarized

Coverage Summary

Policy 02.01.82 (effective 2024-08-01, last reviewed 2025-08-01; status: CURRENT) defines Wellmark's coverage position for High-Intensity Laser Therapy (HILT). The scope covers Class IV (>500 mW) non-surgical lasers for musculoskeletal conditions and Bell's palsy and provides coding and policy history. The policy stance classifies HILT as investigational (not covered) for chronic musculoskeletal pain, Bell's palsy, and all other indications, and notes that claims for these indications are subject to denial as not medically necessary under this policy.

Policy summary — High Intensity Laser Therapy (HILT)

Policy number02.01.82

PayerBlue Cross Blue Shield - South Dakota (Wellmark)

Effective date2024-08-01

Last review2025-08-01

Coverage stanceInvestigational / Not covered

Indications listed as investigational3

CPT / Unlisted codes listed4 (e.g., 17999, 97039, 97139, 99199)

Key findingsSRs/RCTs show some small-to-moderate improvements in pain and function but methodological limitations and heterogeneity limit confidence

Policy Coverage Determinations

Coverage stance for HILT by indication:

Chronic musculoskeletal pain: High Intensity Laser Therapy (HILT) for treatment of chronic musculoskeletal pain is considered investigational.
Evidence insufficient to determine improvement in net health outcome.
Bell's palsy: HILT for treatment of Bell's palsy is considered investigational.
Evidence insufficient to determine improvement in net health outcome.
All other indications: HILT for the treatment of all other indications is considered investigational.
Evidence insufficient to determine improvement in net health outcome.

Billing, Documentation, and Denial Guidance

Documentation Required

Use appropriate unlisted CPT for billing

Report HILT services using appropriate unlisted CPT codes and include required device and procedure details when submitting claims for unlisted codes.

17999
97039
97139
99199
When using unlisted codes, specify the device and procedure details as required for unlisted CPT reporting.

Denial Risk

Services considered investigational — coverage denial risk

High-intensity laser therapy (HILT) for chronic musculoskeletal pain, Bell's palsy, and all other indications is considered investigational; claims for these indications are therefore subject to denial as not medically necessary per this policy.

Coding Guidance

Unlisted CPT potentially used for HILTCPT

17999	Unlisted procedures, skin, mucous membrane and subcutaneous tissue (may be utilized for high-intensity laser therapy: Diowave Laser System, ESPT-3X, K-Laser, LCT-1000, OptonPro).
97039	Unlisted modality (specify type of time if constant attendance) (may be utilized for high-intensity laser therapy: Diowave Laser System, ESPT-3X, K-Laser, LCT-1000, OptonPro).
97139	Unlisted therapeutic procedure (specify) (may be utilized for high-intensity laser therapy: Diowave Laser System, ESPT-3X, K-Laser, LCT-1000, OptonPro).
99199	Unlisted special service, procedure or report (may be utilized for high-intensity laser therapy: Diowave Laser System, ESPT-3X, K-Laser, LCT-1000, OptonPro).

Background and Evidence Summary

High-intensity laser therapy (HILT) is described as a Class IV therapeutic non-surgical laser device with power output >500 mW intended to transmit infrared energy beyond the skin to deeper musculoskeletal tissues and to provide temporary relief of muscle spasms and minor muscle/joint pain. Multiple devices have been cleared by the FDA through the 510(k) process (examples include Diowave, ESPT-3X, K-Laser, LCT-1000, and OptonPro). Proposed mechanisms of action include photobiomodulation (anti-inflammatory effects), photothermal effects that increase tissue temperature and muscle relaxation, and analgesic neural modulation (neural inhibition or endorphin-mediated effects). The evidence base includes randomized controlled trials and numerous systematic reviews showing some statistically and clinically significant improvements in pain and function for selected conditions, but the trials have serious methodological limitations and substantial heterogeneity in HILT parameters, cointerventions, and patient characteristics, which reduces confidence and precludes concluding that HILT improves net health outcomes.

Evidence source	Key result / outcome	Notes (GRADE, N, heterogeneity)
Systematic reviews / RCTs (overall umbrella) - multiple SRs and RCTs	SRs and RCTs report statistically and clinically significant improvements in pain and function for some conditions	Serious methodological limitations and heterogeneity across trials; AMSTAR-2 rated many SRs low/critically low; overall evidence judged insufficient to conclude effectiveness
Bell's palsy RCT (Alayat et al., 2013) reported in SRs	RCT (N=48) showed greater improvement with HILT vs exercise; both laser groups improved vs exercise	Single small RCT (3 groups of ~17); methodological limitations (no blinding of therapists/outcome assessors, no ITT), natural recovery of Bell's palsy limits attribution
Knee osteoarthritis network meta-analysis (Khalilizad et al., 2024)	HILT + exercise improved VAS pain and WOMAC vs control; greater reduction vs LLLT+exercise at week 8 (SMDs reported)	11 RCTs, N=433; heterogeneity and small sample sizes noted; limitations in irradiation parameters
Wu et al. (2022) — pain intensity HILT vs placebo (with exercise)	MD: -1.66 cm (95% CI -1.5 to -1.8) on VAS	N=331 across 7 RCTs; I2=0%; GRADE NR in appendix
De la Barra et al. (2023) — shoulder disability (SPADI)	MD: -10.08% (95% CI -16.5 to -3.7) favoring HILT	N=157 (3 RCTs); I2=0%; GRADE=high for SPADI outcome
De la Barra et al. (2024) — pooled PI at rest (VAS) across disorders	MD: -1.45 cm (95% CI -1.8 to -1.0) favoring HILT after treatment	N=1106 (17 RCTs); I2=93%; GRADE=low; substantial heterogeneity
Abdildin et al. (2023) — pain intensity (VAS) at rest	MD: -1.25 cm (95% CI -1.7 to -0.9) favoring HILT	N=87 (2 RCTs); I2=0%; GRADE=high for this outcome
Selected meta-analytic effect sizes (examples across SRs) — overall pain/function	Song et al. (2018) overall PI: MD -1.01 cm (95% CI -1.3 to -0.7); Song et al. neck disability SMD -1.9 (95% CI -3.6 to -0.2)	Song et al totals N=736 (PI overall), I2=55% (PI); neck I2=97%; GRADE NR — highlights variable effect sizes and heterogeneity

Definitions / Acronyms

High-intensity laser therapy (HILT)Class IV therapeutic non-surgical laser device with power output >500 mW capable of transmitting energy beyond the skin to deep musculoskeletal tissues.

CPTconventional physical therapy

DASH

Policy Revision History

2024-08-01revised

Policy revised August 2024: Content regarding 'High Intensity Laser Therapy' moved from medical policy 02.01.14 to new/updated policy 02.01.82 (Original Effective Date and Revised: August 2024).

2025-08-01renewedLatest

Policy renewed at annual review (August 2025).