Anodyne Infrared Therapy
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Defines Geisinger Health Plan's coverage stance for Anodyne (monochromatic infrared/MIRE) therapy across commercial, Medicare, CHIP and Medicaid business segments and describes related definitions and coding. Affects providers submitting claims or prior authorization requests to Geisinger Health Plan.
No material clinical or coverage changes in this revision.
Coverage Determination
Coverage stance
Coverage determination for Anodyne Infrared Therapy:
Geisinger Technology Assessment Committee concluded insufficient evidence.
PA Medicaid applies policy as written; other lines of business follow eligibility, contract-specific benefits, limitations and exclusions and may require case-by-case evaluation.
The Plan does NOT provide coverage for Anodyne Infrared Therapy because it is considered unproven. The Geisinger Technology Assessment Committee reviewed the technology and concluded that there is insufficient evidence in the peer‑reviewed published medical literature to establish effectiveness on health outcomes compared with established tests or technologies.
Coverage for experimental or investigational treatments, services and procedures is specifically excluded under the member's certificate with Geisinger Health Plan. Providers should note that unproven services delivered outside of an approved clinical trial are also specifically excluded under the member's certificate.
Anodyne Infrared Therapy is considered unproven and therefore not medically necessary under this policy due to the lack of sufficient evidence demonstrating improved health outcomes.
Unproven services that are not part of an approved clinical trial are excluded from coverage under the member's certificate. This policy does not expand coverage to items or services that are specifically excluded by the member's contract; prior authorization and precertification requirements may still apply.
Billing and Code Listings
Provider Requirements, Prior Authorization, and Billing Notes
Confirm benefit documents and applicable LOB rules before scheduling
Coverage and any required review are subject to the member’s line-of-business benefit documents; for Medicare, applicable LCDs/NCDs supersede this policy. For the Pennsylvania Medicaid (PA Medicaid) business segment, this policy applies as written and nonconforming requests may be evaluated case-by-case.
- Eligibility and contract-specific benefits, limitations and exclusions will apply and supersede this policy when specified.
- Medicare coverage is governed by LCDs/NCDs; consult CMS or the local MAC for Medicare coding/coverage.
Check Geisinger prior authorization and precert lists
Prior authorization and/or precertification may be required per the member’s contract; providers should consult Geisinger’s prior authorization resources before scheduling services.
- Prior authorization requirements can be found at: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
- Precertification lists are in the member’s contract-specific benefit document.
Document medical necessity for heat-modality use in PA Medicaid
If treating under the PA Medicaid business segment, document medical necessity when using infrared as a heat modality in a physical therapy regimen; nonconforming requests may be evaluated case-by-case.
- Note the explicit PA Medicaid exception: infrared treatment is covered when medically necessary as a heat modality in a PT regimen.
- Retain documentation showing why modality is integral to the PT plan of care.
Avoid authorization requests for Anodyne therapy outside the PA Medicaid exception
Do not request authorization for Anodyne Infrared Therapy as a covered therapy outside of the PA Medicaid heat-modality exception without strong supporting evidence—such requests are subject to denial as unproven.
- The Plan does NOT provide coverage for Anodyne Infrared Therapy because it is considered unproven.
- Requests that do not meet PA Medicaid criteria may be evaluated case-by-case but are generally excluded.
Bill with appropriate unlisted modality/procedure codes and specify type/time
When billing for infrared-type services, include an appropriate unlisted CPT/HCPCS code and specify the modality type and time or other details required by that unlisted code (e.g., 97039, 97139, 97799). Inclusion of these codes is informational and does not guarantee coverage.
Use Geisinger clinical policies and member precert lists for PA instructions
Providers should consult Geisinger Health Plan’s providers clinical policies page for prior authorization instructions and check the member’s contract-specific precertification lists before scheduling.
- Prior authorization requirements and clinical policy guidance: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
- Precertification lists are in the member’s contract-specific benefit document.
Anodyne Infrared Therapy requests are denied as unproven
Requests for Anodyne Infrared Therapy will be denied because the Plan considers the therapy unproven due to insufficient evidence of effectiveness in peer-reviewed literature.
- Geisinger Technology Assessment Committee concluded there is insufficient peer‑reviewed evidence to establish effectiveness.
- Denials will follow the Plan’s exclusion for Anodyne Infrared Therapy as unproven.
Exclusion risk: experimental/investigational and unproven services are not covered
Coverage for experimental, investigational or unproven treatments is specifically excluded under the member’s certificate; prior authorization requirements may still apply, and services outside an approved clinical trial are excluded.
- This policy does not expand coverage to items specifically excluded in the member’s certificate; see MP015 for the evaluation process.
- Prior authorization and/or precertification requirements for items may apply and precert lists are in the member’s benefit document.
Background
Anodyne Infrared Therapy, also called Monochromatic Infrared Energy (MIRE), delivers monochromatic near‑infrared photo energy from superluminous gallium aluminum arsenide diode arrays applied in a flexible pad in contact with the skin. The device is proposed to work by releasing nitric oxide from hemoglobin and proteins, which may relax smooth muscle in vessels and lymphatics, and has been marketed and evaluated for indications including chronic nonhealing wounds, diabetic peripheral neuropathy and lymphedema.
Definitions
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