Low-level laser therapy (LLLT) (Photobiomodulation) for Prevention of Oral Mucositis
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Defines medical necessity, coding, and prior authorization documentation for use of low-level laser therapy (photobiomodulation) to prevent oral mucositis in patients receiving cancer treatments that increase mucositis risk; applies to eocco members and their providers.
New medical policy establishing coverage criteria for LLLT (photobiomodulation) for prevention of oral mucositis in high-risk cancer treatments.
Coverage Criteria and Medical Necessity
Medical Necessity - Prevention of Oral Mucositis
Covered when ALL of the following are met
LLLT is considered medically necessary for prevention of oral mucositis in these populations per policy.
LLLT is not medically necessary for treatment of indications other than prevention of oral mucositis. Examples of excluded indications include, but are not limited to: adhesive capsulitis, Bell palsy, carpal tunnel syndrome, fibromyalgia, hair loss, heel pain (e.g., plantar fasciitis), low back pain, lymphedema, neck pain, osteoarthritic knee pain, pressure ulcers, rheumatoid arthritis, skin burn, and wound healing.
Use of low-level laser therapy (LLLT) for any of the non‑mucositis indications listed in this policy is explicitly not medically necessary and will be subject to denial. Requests for LLLT to treat these conditions should not be submitted as services eligible for coverage under this policy.
Coding and Diagnosis Codes
| 0552T | Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional. |
| 1011T | Photobiomodulation (PBM) therapy of oral cavity, including placement of an oral device, monitoring of patient tolerance to treatment, and removal of the oral device. |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscle(s). |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles. |
| S8948 | Application of a modality to 1 or more areas; low-level laser therapy (ie, nonthermal and non-ablative) for post-operative pain reduction Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes. |
| K12.30-K12.39 | Oral mucositis (ulcerative). |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required for LLLT for prevention of oral mucositis
Prior authorization is required for LLLT when used for prevention of oral mucositis in members undergoing cancer treatment with increased mucositis risk. The prior authorization submission must include clinical documentation showing medical necessity and relevant history and physical (H&P) notes. Coverage is limited to prevention of oral mucositis in these patients.
- Include documentation that the member is receiving chemotherapy, radiotherapy, or hematopoietic cell transplantation associated with increased mucositis risk.
- Attach H&P notes supporting the need for prophylactic LLLT.
Step therapy
(No specific step therapy requirements are specified in this policy.)
Required documentation for prior authorization
Submit clinical documentation that indicates medical necessity and include the member’s history and physical clinical notes supporting the need for low-level laser therapy.
- Clinical documentation must demonstrate the indication is prevention of oral mucositis related to cancer treatment.
- Attach H&P notes with relevant findings and treatment plan.
Denial risk for non-covered indications
Requests for LLLT for indications other than prevention of oral mucositis (for example adhesive capsulitis, Bell palsy, carpal tunnel syndrome, wound healing, etc.) are not medically necessary and are subject to denial.
- Deny requests for non-mucositis indications listed in the policy.
- Ensure submitted indication matches cancer treatment–related mucositis prevention.
Background
Oral mucositis is inflammation and ulceration of the oral mucosa that commonly occurs as a consequence of cancer therapies. It is frequently caused by chemotherapy, radiotherapy, or hematopoietic cell transplantation, and can result in significant pain, impaired oral intake, infection risk, and interruptions to cancer treatment. Low-level laser therapy (photobiomodulation) has been evaluated as a noninvasive prophylactic intervention to reduce the incidence and severity of therapy-related oral mucositis.
Definitions
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