Low-Level Laser Therapy (Photobiomodulation)
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This policy governs medical necessity and investigational determinations for low-level laser therapy (photobiomodulation), specifying when LLLT is considered medically necessary (prevention of oral mucositis in certain cancer patients) and when it is investigational.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indication
Covered when ALL of the following are met
Treatment timing in studies: for chemotherapy/chemoradiation courses generally from day 0 through treatment; in HCT studies began between day -7 and day 0 and continued up to about day 14–15; protocols that began at day -7 to -5 ended at day -1 to day 0.
Prevention of oral mucositis
Covered when ALL of the following are met
Supported by systematic reviews and randomized trials showing reduction in severe oral mucositis.
Investigational indications
Not covered / investigational
There is insufficient evidence to support a general conclusion concerning the health outcomes for these indications.
Investigational / Insufficient Evidence Indications
Not covered / considered investigational for other indications due to insufficient evidence
Systematic reviews and RCTs are inconsistent or limited by small sample sizes, heterogeneity in laser parameters, and methodological flaws.
The policy states that laser acupuncture — defined as application of low-level laser energy to acupuncture points on the fingers and hand — is not reviewed in this document.
Low-level laser therapy (LLLT) when used for pain (non-oral mucositis indications) is listed as investigational and therefore not covered under this policy; the procedure-code table in the policy maps investigational uses to procedure codes (e.g., 0552T and others) consistent with that stance.
There are no explicit exclusions provided in this portion of the policy beyond the investigational determinations and the statement on laser acupuncture; the document segment does not list additional exclusion language.
Per the policy history, the Benefit Variations section was removed in an administrative update effective 09/03/2025. Any specific benefit variations or plan-level exclusions are therefore governed by member plan documents rather than by this policy.
Aside from the single medically necessary indication for prevention of oral mucositis, the policy considers the use of LLLT for pain and many musculoskeletal and neurologic conditions to be investigational or unsupported by sufficient evidence; examples listed include carpal tunnel syndrome, low back pain, osteoarthritis of the knee, tendinopathies, temporomandibular disorders, rheumatoid arthritis, fibromyalgia, chronic nonhealing wounds, and lymphedema.
This segment does not provide any explicit determinations using the label “not medically necessary”; the document content here frames non-covered uses as investigational and refers readers to plan documents for benefit-specific decisions.
Coding
| K190572 | Erchonia FX-635 510(k) clearance |
| K171354 | Multi Radiance Medical Super Pulsed Laser Technology 510(k) |
| K081166 | SOLICA Lightstream Low-Level Laser 510(k) |
| K050668 | GRT LITE, Model 8-A 510(k) |
| K010175 | MICROLIGHT 830 Laser System 510(k) |
| 0552T | Procedure code referenced for investigational and covered listings (context-specific) |
| 1011T | Procedure code listed as covered when medically necessary for prevention of oral mucositis |
| D9128 | Procedure code listed as covered when medically necessary for prevention of oral mucositis |
| 97037 | Code referenced in the investigational list mapping |
| D9129 | Code referenced in the investigational list mapping |
| S8948 | Code referenced in the investigational list mapping |
| K12.31 | Oral mucositis (ulcerative) due to antineoplastic therapy |
| K12.33 | Oral mucositis (ulcerative) due to radiation |
| K12.39 | Other oral mucositis (ulcerative) |
| 0052T | Procedural code referenced in policy history (corrected earlier) |
| 0552T | Code referenced as added to medical necessity in prior update |
| 97037 | Code added 12/12/2023 administrative update |
| 1011T | New code added 01/01/2026 per administrative update |
| D9128 | New dental/HCPCS-like code added 01/01/2026 per administrative update |
| D9129 | New dental/HCPCS-like code added 01/01/2026 per administrative update |
| 1026T | New code added 06/09/2026 administrative update (effective date noted in history) |
Provider Actions & Documentation
Prior authorization expectation for indications
Prior authorization is implied where benefit variations apply; LLLT is medically necessary only for prevention of oral mucositis in higher‑risk cancer treatment patients and requests for non‑mucositis indications are likely to be denied.
- LLLT considered medically necessary only for prevention of oral mucositis in patients undergoing cancer treatment associated with increased risk of oral mucositis.
- LLLT is investigational for all other indications (e.g., CTS, neck pain, low back pain) and those requests are unlikely to meet medical necessity.
Prior authorization — oral mucositis prevention codes
Procedure codes 0552T, 1011T, and D9128 are listed as covered when medically necessary for prevention of oral mucositis in patients undergoing cancer treatment; use these codes when requesting authorization for the covered mucositis indication.
Prior authorization process not specified
No specific prior authorization process or requirements are specified in the provided document portion; local benefit plan terms and authorization workflows apply.
- Policy text contains no procedural prior authorization steps in this segment.
- Contact Capital BlueCross Provider Services for plan‑specific authorization procedures.
Use current codes for authorization and claims
Policy history documents codes added and removed over time; prior authorization and claims are dependent on using the current, effective CPT/HCPCS codes.
Expect conservative therapy before LLLT for musculoskeletal conditions
For musculoskeletal conditions such as carpal tunnel syndrome, standard conservative therapies (e.g., splinting, activity modification, medications, injections) are expected before considering adjunctive modalities like LLLT.
- Mild‑to‑moderate CTS is usually first treated conservatively with splinting and cessation of aggravating activities.
- Other conservative options include oral steroids, diuretics, NSAIDs, and steroid injections; surgery considered for severe or refractory cases.
Verify benefits and anticipate denials for non‑covered uses
Additional provider action: highlight investigational status — providers should proactively verify benefit terms and anticipate denials for non‑mucositis uses.
- Confirm member benefit coverage and medical necessity criteria prior to treatment for indications other than oral mucositis.
- Expect investigational uses to be declined per policy language listing multiple non‑mucositis indications as investigational.
No step therapy requirements specified
No step therapy requirements are described in this policy segment.
- The policy does not specify step therapy protocols or mandatory trials prior to LLLT for any indication in this segment.
Recommended timing for oral mucositis prevention
Timing of LLLT for oral mucositis prevention should follow studied protocols: for chemotherapy/chemoradiation, LLLT was generally given from day 0 through the course of treatment; for HCT, LLLT began between day −7 and day 0 and continued through about day 14–15.
- HCT studies: began between day −7 and day 0; protocols that began at day −7 to −5 ended at day −1 to day 0; other HCT courses continued through approximately day 14–15.
- Chemotherapy/chemoradiation studies: course generally from day 0 through treatment.
Documentation to support medical necessity
Document the diagnosis and medical necessity when requesting coverage for oral mucositis prevention; use the diagnosis codes and procedure codes listed in the policy to support the request.
- Supported ICD‑10 codes for oral mucositis prevention: K12.31, K12.33, K12.39.
- Include clinical documentation showing the patient is undergoing cancer treatment associated with increased risk of oral mucositis and that timing aligns with studied protocols.
Documentation requirements not specified in this segment
This segment does not provide detailed documentation templates or administrative documentation requirements; it contains policy identifiers and literature citations only.
- No explicit documentation requirements (e.g., visit notes, treatment logs) are specified in this portion of the policy.
- Providers should retain clinical records that substantiate diagnosis, treatment timing, and rationale for LLLT use.
Document and bill using current codes
Use the current CPT/HCPCS codes as listed in policy updates when submitting prior authorization requests and claims; the policy history shows administrative coding updates that affect which codes are appropriate.
Do not expect coverage for investigational indications
Providers should note that LLLT is investigational for indications other than oral mucositis and should not expect coverage for those uses.
- LLLT listed as investigational for many indications including CTS, neck pain, TMJ pain, low back pain, knee OA, wound healing, and lymphedema.
- Requests for these indications may be denied as not medically necessary under this policy.
Investigational uses may be denied
Claims for investigational uses of LLLT (e.g., for pain or musculoskeletal conditions) may be denied or returned because those uses are considered investigational and not covered under this policy.
- Policy explicitly lists LLLT for pain as investigational; investigational uses are therefore not covered.
- Submitters should expect denials for claims lacking a covered indication per policy.
No explicit authorization or billing procedure in this segment
This policy segment does not specify explicit authorization or billing procedures; providers must follow plan‑specific authorization and billing rules and contact Provider Services for details.
- Documented policy text in this segment contains policy identification but no procedural authorization steps.
- Payment of claims is subject to member benefit terms, eligibility, and medical necessity determinations.
Risk from administrative and coding updates
Coding and administrative updates in the policy history create risk for claim denials if outdated codes are used; confirm code changes before submission.
Background
Low-level laser therapy (photobiomodulation) employs red or near-infrared wavelengths, typically described in the literature and policy as approximately 600–1000 nm, with device power settings in the range of about 5–500 mW. It is hypothesized that these wavelengths penetrate tissues and produce photobiostimulatory effects (reduced pain, improved tissue healing, or modulation of biological markers), although the exact mechanism remains uncertain.
Definitions
Revision History
Corrected procedure code from 0052T to 0552T in policy history entry.
Consensus review including background, rationale, and coding; references added with no change to policy statement.
Consensus review updated references, description/background, and summary of evidence; no change to policy statement.
Consensus review with removal of code 97026 and addition of 0552T to medically necessary listing when criteria are met.
Consensus review updating background and rationale; references added; no change to policy statement.
Added new code 97037 via administrative update (effective 01/01/2024).
Consensus review with rationale updated and references added; no change to policy statement.
Consensus review removing NCCN statement and updating benefit variation and disclaimer; no change to policy statement.
Administrative update removing Benefit Variations section and updating the disclaimer.
Added new codes 1011T, D9128, and D9129 to policy (effective 01/01/2026).
Added new code 1026T to the policy (effective date noted in history).
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