CurrentCapital BluecrossPolicy MP 1.097

Low-Level Laser Therapy

Governs medical necessity and investigational determinations for low-level laser therapy for members covered by Capital BlueCross, focusing on prevention of oral mucositis in cancer patients and other indications.

Policy Summary

PayerCapital Bluecross

PolicyLow-Level Laser Therapy

Policy CodePolicy MP 1.097

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen seeking coverage, document that LLLT is being used to prevent oral mucositis in patients undergoing cancer treatment and follow timing/protocols consistent with clinical studies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered indication

>10Investigational indications

600-1000 nmDevice wavelength

2025-12-11New codes listed

9Policy history entries

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Coverage Criteria: Medical Necessity and Investigational Uses

Evidence citations

Evidence citations — references and systematic reviews that informed coverage determinations:

Oberoi et al. (2014) meta-analysis of 18 trials on LLLT for prevention of oral mucositis — course of LLLT typically from day 0 through treatment; in HCT studies LLLT began between day -7 and day 0 and continued as long as day 14–15 (see Policy Guidelines).

Multiple systematic reviews and randomized controlled trials demonstrating reduction in severe oral mucositis with prophylactic LLLT in patients undergoing chemotherapy, radiotherapy, chemoradiotherapy, and hematopoietic cell transplantation; evidence judged sufficient to improve net health outcome for this indication.

Systematic reviews, TEC Assessment (2010), and RCTs for musculoskeletal and neurologic indications (e.g., carpal tunnel, neck pain, low back pain, osteoarthritis knee pain, heel pain) showing inconsistent or low-quality evidence; insufficient to support improvement in net health outcome.

Randomized trials and systematic reviews for rheumatoid arthritis, Bell palsy, fibromyalgia, wound healing, and lymphedema with methodological limitations, small sample sizes, heterogeneity of laser types/dosages/schedules, and inconsistent findings — evidence insufficient to support effectiveness.

Selected cited RCTs and observational studies for temporomandibular disorders and myofascial pain (Oz et al. 2010; Marini et al. 2010; Santos et al. 2010; Rohlig et al. 2011; Wang et al. 2011; Sattayut & Bradley 2012; de Carli et al. 2013) included in the evidence base but overall do not establish consistent benefit across non-mucositis indications.

Recent and historical references for plantar fasciitis and heel pain (Ferlito et al. 2023; Macias et al. 2015; Kiritsi et al. 2010; Cinar et al. 2018) and rheumatoid arthritis (Brosseau et al. 2005; Lourinho et al. 2023; Meireles et al. 2010) illustrate ongoing investigational status for these conditions due to inconsistent results and heterogeneity.

Reference list excerpt: Oz S et al. J Craniofac Surg. 2010; Marini I et al. Clin J Pain. 2010; Santos Tde S et al. Braz J Otorhinolaryngol. 2010; Rohlig BG et al. Turk J Phys Med Rehabil. 2011; Wang X et al. Hua Xi Kou Qiang Yi Xue Za Zhi. 2011; Sattayut S & Bradley P. Laser Ther. 2012; de Carli ML et al. J Oral Rehabil. 2013; Ferlito JV et al. Lasers Med Sci. 2023; Macias DM et al. J Foot Ankle Surg. 2015; Kiritsi O et al. Lasers Med Sci. 2010; Cinar E et al. Lasers Med Sci. 2018; Brosseau L et al. Cochrane Database Syst Rev. 2005; Lourinho I et al. PLoS One. 2023; Meireles SM et al. Clin Rheumatol. 2010.

Coding: Procedure, Device and Diagnosis Codes

Selected FDA 510(k) device numbers and indicationsmixed

K190572	510(k) number for FX-635 (Erchonia Corporation) - cleared for adjunctive use in whole body musculoskeletal pain therapy
K171354	510(k) number for Super Pulsed Laser Technology (Multi Radiance Medical) - providing temporary relief of minor chronic neck and shoulder pain of musculoskeletal origin
K081166	510(k) number for Lightstream Low-Level Laser (Solica Corporation) - adjunctive use in the temporary relief of pain associated with knee disorders
K050668	510(k) number for GRT LITE, MODEL 8-A (GRT Solutions, Inc.) - use in providing temporary relief of minor chronic neck and shoulder pain of musculoskeletal origin
K010175	510(k) number for MICROLIGHT 830 LASER SYSTEM (Microlight Corporation of America) - indication for use in pain therapy or related indication

Procedure codes (investigational for pain; some covered for oral mucositis prevention)CPT | HCPCS | DENTAL

0552T	Procedure code (listed both investigational for pain and covered for oral mucositis prevention in the policy)
97037	Procedure code (listed investigational for pain; added to policy history effective 01/01/2024)
D9128	Dental procedure code (listed in both investigational and covered contexts; added in policy history effective 01/01/2026)
D9129	Dental procedure code (listed in both investigational and covered contexts; added in policy history effective 01/01/2026)
S8948	Procedure code (listed in both investigational and covered contexts)
1011T	Procedure code (listed as covered for oral mucositis prevention)

ICD-10 CM Diagnosis Codes for covered oral mucositis preventionICD-10Covered

K12.31	Oral mucositis (ulcerative) due to antineoplastic therapy
K12.33	Oral mucositis (ulcerative) due to radiation
K12.39	Other oral mucositis (ulcerative)

Codingmixed

No CPT/HCPCS/ICD codes are listed in these chunks.

Policy coding changes and relevant CPT/HCPCS codesmixed

0552T	Procedure code corrected/added in policy history (corrected from 0052T; added to medically necessary listing when criteria met)
97037	New code added (effective 01/01/2024) per policy history
1011T	New code added (effective 01/01/2026) per policy history
D9128	New code added (effective 01/01/2026) per policy history
D9129	New code added (effective 01/01/2026) per policy history
97026	Code removed from policy (per policy history)

Device wavelength — technical range for LLLT devices

Wavelength range600–1000 nm

Device power — device power range referenced in policy

Power range5–500 mW

Provider Actions: Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Product/program prior authorization note

Prior authorization may be required for certain programs and products administered by Capital Blue Cross. Providers should verify benefit plan-specific requirements prior to scheduling LLLT services.

Applies only to certain programs/products administered by Capital Blue Cross; see product variations and plan documents for details
FEP PPO: refer to FEP Medical Policy Manual (https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies)

Denial Risk

Investigation / noncoverage for pain indications

Low-level laser therapy (LLLT) is investigational and therefore not covered for pain indications. Billing for LLLT when used for pain (investigational/noncovered indications) may be denied if submitted with the listed procedure codes.

Investigational / not covered for pain: 0552T, 97037, D9128, D9129, S8948

Background and Context

Low-level laser therapy (LLLT), also called photobiomodulation, uses red-beam or near-infrared lasers in the wavelength range of 600–1000 nm with low power output (typically 5–500 mW) that produce no sensation or skin burn. The therapeutic rationale is that low-intensity light may have photobiostimulatory effects on tissue, and LLLT is being evaluated for indications including oral mucositis, musculoskeletal pain, lymphedema, and chronic wounds.

Evidence summarized in the policy supports LLLT for the prevention of oral mucositis in patients undergoing cancer therapy at increased risk, while for most other indications the evidence is inconsistent, limited by small or flawed trials, and insufficient to conclude net patient benefit.

Definitions

Low-level laser therapy (LLLT) / Photobiomodulation — device wavelength/power and general definition

DefinitionTherapeutic use of red-beam or near‑infrared lasers (wavelength 600–1000 nm) at low power that produces no sensation or skin burn and is hypothesized to have photobiostimulative effects on tissue.

Typical device powerDevices operate between 5 and 500 mW (low power compared with surgical lasers).

Clinical intentEvaluated to reduce pain, inflammation, and promote tissue healing across indications including oral mucositis, musculoskeletal pain, tendinopathies, nerve injuries, and lymphedema.

Oral mucositis — definition and clinical course

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

Clinical course

Revision History

2025-12-11coding update

Administrative update added new codes 1011T, D9128, and D9129 effective 01/01/2026.

2025-09-03administrative update

Removed Benefit Variations section and updated Disclaimer.

2025-04-17consensus review

Consensus review with rationale updated and NCCN statement removed; no change to policy statement.

Policy Summary

PayerCapital Bluecross

PolicyLow-Level Laser Therapy

Policy CodePolicy MP 1.097

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen seeking coverage, document that LLLT is being used to prevent oral mucositis in patients undergoing cancer treatment and follow timing/protocols consistent with clinical studies.

SourceLink

On This Page

Providers should not bill these codes expecting coverage for pain-related indications

Billing Rule

Covered use and billing when medically necessary

When LLLT is used for prevention of oral mucositis and meets medical necessity criteria in this policy, it is covered using the listed procedure and diagnosis codes. Documentation should support the indication, timing, and treatment protocol consistent with the clinical evidence.

Covered procedure codes (when medically necessary for prevention of oral mucositis): 0552T, 1011T, D9128, D9129, S8948
Required ICD-10-CM diagnosis codes for coverage: K12.31, K12.33, K12.39

Note

Code updates affecting authorization

Policy history documents code updates and administrative changes that may affect authorization and billing. Providers should use the most current codes and effective dates when submitting claims.

04/14/2020: Corrected procedure code 0052T to 0552T
07/20/2022: Code 97026 removed; 0552T added to medically necessary list if criteria met
12/12/2023: New code 97037 added (effective 01/01/2024)
12/11/2025: Added new codes 1011T, D9128, D9129 (effective 01/01/2026)

Documentation Required

Recommended treatment timing documentation

Recommended treatment timing and protocol for prevention of oral mucositis should be documented consistent with clinical studies: typically beginning at day 0 through the course of cytotoxic therapy; in HCT studies, beginning between day -7 and day 0 and continuing through the high-risk period (commonly through day 14–15). If LLLT is initiated prior to HCT (day -7 to -5), document end date (commonly day -1 to day 0).

Typical course: start day 0 through the antineoplastic treatment course
HCT protocols: start between day -7 and day 0 and continue through day 14–15 (or as clinically indicated)
If started pre-HCT (day -7 to -5), document stop date (often day -1 to day 0)

Documentation Required

Documentation to support oral mucositis prevention

Documentation required to support coverage for prevention of oral mucositis should be included in the medical record and available upon request.

Clinical indication: diagnosis of oral mucositis due to antineoplastic therapy or radiation (use K12.31, K12.33, K12.39 as applicable)
Treatment schedule: start and stop dates, frequency and number of LLLT sessions, and protocol used (including device/site treated)
Risk context: evidence patient is undergoing cancer treatment associated with increased risk of oral mucositis (e.g., chemotherapy, radiotherapy, hematopoietic stem cell transplantation)
Response and monitoring: documentation of mucositis status and any treatment response or adverse events

Note

No explicit prior authorization or denial triggers contained

No explicit prior authorization, specific preauthorization forms, or explicit denial triggers are listed in the excerpts provided. Providers should verify plan-specific administrative requirements and submit complete documentation to avoid delays or denials.

The policy excerpts do not specify a universal prior authorization process or explicit denial triggers beyond investigational/noncoverage statements
Plan-level benefit variations may impose additional authorization or documentation requirements

Can cause significant pain, increased risk of systemic infection, need for total parenteral nutrition, and use of narcotic analgesics.

Context for coveragePreventive LLLT is considered medically necessary for patients undergoing cancer treatments associated with increased risk of oral mucositis when applied per study protocols.

Carpal Tunnel Syndrome — definition

DefinitionCondition of pain or numbness affecting part of the median nerve distribution of the hand (thumb, index, radial half of ring finger, radial half of palm) and may radiate into the arm.

Typical symptomsParesthesia, burning, weakness, or pain in median nerve territory often exacerbated by activity.

Policy stanceLLLT for carpal tunnel syndrome is listed as investigational/insufficient evidence in this policy.

Epicondylitis — definition

DefinitionInflammation of the epicondyle of the humerus and surrounding tissues (commonly manifests as lateral or medial elbow pain).

Clinical relevanceOften assessed in trials of photobiomodulation for tendinopathies and musculoskeletal pain.

Policy stanceLLLT for epicondylitis is considered investigational/insufficient evidence in this policy.

Fibromyalgia — definition

DefinitionChronic pain syndrome characterized by widespread musculoskeletal pain often difficult to manage, affecting muscles and soft tissues surrounding joints.

Evidence contextSeveral clinical trials and randomized studies of photobiomodulation in fibromyalgia are cited but evidence is not conclusive for routine use.

Policy stanceLLLT for fibromyalgia is considered investigational/insufficient evidence per this policy.

Rheumatoid Arthritis — definition

DefinitionChronic systemic disease marked by inflammation of multiple synovial joints, often resulting in pain, swelling, and functional impairment.

Clinical trialsRandomized trials and systematic reviews of LLLT in rheumatoid arthritis are cited (e.g., Cochrane review), but benefits are not established.

Policy stanceLLLT for rheumatoid arthritis is considered investigational/insufficient evidence in this policy.

Tendinitis — definition

DefinitionInflammation of a tendon, often presenting with localized pain and impaired function.

Common examplesIncludes Achilles tendinopathy and other overuse-related tendon disorders evaluated in LLLT studies.

Policy stanceLLLT for tendinitis/tendinopathy is considered investigational/insufficient evidence per this policy.

TMJ Syndrome — definition

DefinitionSevere pain in and about the temporomandibular joint, typically worsened by chewing.

Clinical evaluationIncluded in randomized trials of photobiomodulation for temporomandibular disorders (TMD).

Policy stanceLLLT for TMJ/TMD is considered investigational/insufficient evidence in this policy.

Low-level laser therapy (LLLT) / photobiomodulation — alternate definitional text and clinical intent

Alternate definitionPhotobiomodulation or LLLT is the therapeutic application of low‑power lasers or LEDs (commonly 600–1000 nm, 5–500 mW) intended to reduce pain and inflammation and to promote tissue healing without producing heat or burns.

Mechanism hypothesisHypothesized photobiostimulative effects include improved cellular repair and stimulation of immune, lymphatic, and vascular systems; exact mechanism remains uncertain.

Clinical intentApplied as an adjunctive therapy across conditions—analgesia, wound healing, and prevention of treatment‑related oral mucositis—per clinical trial protocols.

Photobiomodulation / LLLT — additional definitional content from references

Definition from referencesTherapeutic use of low‑intensity light (lasers/LEDs) across various wavelengths to treat pain, inflammation, wound healing, and neuropathic conditions as represented in multiple RCTs and systematic reviews.

Evidence baseThe policy references numerous randomized controlled trials and systematic reviews across indications (e.g., osteoarthritis, tendinopathy, wound healing, Bell’s palsy, TMD).

Uncertain efficacyDespite multiple studies, the document concludes evidence is sufficient only for prevention of oral mucositis while other indications remain insufficient or investigational.

2024-07-05consensus review

Consensus review; no change to policy statement; background and rationale updated and references added.

2023-12-12administrative update

Added new code 97037 effective 01/01/2024.

2022-07-20consensus review and coding change

Consensus review with no change to policy statement; code 97026 removed and 0552T added to medically necessary if criteria met.

2021-10-07consensus review

Consensus review; no change to policy statement; references, description/background, and summary of evidence updated and FEP language updated.

2020-05-08consensus review

Consensus review; background, rationale, and coding reviewed and references added; no change to policy statement.

2020-04-14administrative updateLatest

Corrected procedure code 0052T to read 0552T.