Currentpriority healthPolicy N/A

Monochromatic Phototherapy (Anodyne/MIRE/Low-Level Light Therapy)

This policy governs coverage of monochromatic phototherapy (skin contact monochromatic infrared energy, MIRE, Anodyne therapy, and other low-level light/infrared therapies) for all indications under Priority Health products and describes applicability to product types and prior authorization framework.

Policy Summary

Payerpriority health

PolicyMonochromatic Phototherapy (Anodyne/MIRE/Low-Level Light Therapy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionIf prior authorization is required by the member's product, submit a request demonstrating medical necessity per the Priority Health Provider Manual.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance

2025-09-01Effective

2004–2025Review range

6 codesCoding exclusions

Neuropathy, OA, painIndications mentioned

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Coverage Determination

Overall Coverage Determination

Monochromatic phototherapy is considered investigational and experimental for any indication.

General stance: Monochromatic phototherapy (skin contact monochromatic infrared energy) or other types of low-level light therapy is considered investigational & experimental as a treatment technique for any indication

Includes but not limited to listed indications

Listed Indications

Examples of specific indications explicitly mentioned as investigational include, but are not limited to:

Listed indications: Cutaneous ulcers; Diabetic neuropathy; Lymphedema; Peripheral neuropathy; Soft tissue pain and musculoskeletal conditions (e.g., temporomandibular disorders, tendonitis, capsulitis, knee pain, myofascial pain)

Non-exhaustive list from policy

The following CPT/HCPCS codes are explicitly listed as Not Covered for monochromatic phototherapy and related low‑level light/infrared treatments: 0552T, 1011T, 97026, A4639, E0221, S8948.

This policy document is provided for informational purposes and does not itself authorize services. Receipt of benefits is subject to the member's plan terms and conditions and verification of eligibility; prior authorization requirements, if any, must be confirmed through the member's specific plan and the Priority Health Provider Manual.

Monochromatic phototherapy (including skin contact monochromatic infrared energy, MIRE/Anodyne, and other low‑level light/infrared therapies) is considered investigational and experimental and therefore not medically necessary for any indication under this policy.

Billing and Coding

Not Covered CodesmixedNot Covered

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.
97026	Application of a modality to one or more areas; infrared.
A4639	Replacement pad for infrared heating pad system, each.
E0221	Infrared heating pad system.
S8948	Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes.

Provider Actions and Authorization

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required. Providers must check member-specific benefits and, when prior authorization is required, submit a request demonstrating that the drug, service, or procedure is medically necessary per Priority Health prior authorization rules. For more information, refer to the Priority Health Provider Manual.

Action: Verify member eligibility and benefits before scheduling services.
When required: Submit medical necessity documentation with the prior authorization request.

Note

Policy Is Informational — Authorization Not Specified Here

This section does not by itself authorize services. Providers remain responsible for confirming eligibility, benefits, and whether prior authorization applies for the member’s plan. Receipt of this policy is informational only and does not replace plan-specific authorization or benefit determinations.

Check the member's plan documents and benefit files for authorization requirements.
Policies do not guarantee coverage; benefits are subject to plan terms and conditions.

Background

Monochromatic phototherapy (also described as MIRE, Anodyne therapy, or low‑level infrared/low‑level light therapy) is a noninvasive treatment that applies concentrated infrared or low‑energy light—commonly using devices with pads or diodes—to the skin. It is proposed to increase local circulation, stimulate nitric oxide release, reduce inflammation, and promote tissue healing, and has been evaluated for conditions such as diabetic peripheral neuropathy, wounds, lymphedema, and musculoskeletal pain. Systematic reviews and randomized trials provide inconsistent or insufficient evidence of sustained clinical benefit, which informs the policy determination that these therapies remain investigational.

Key Definitions

MIRE / Anodyne — definition

TermMonochromatic infrared energy (MIRE) / Anodyne Therapy System

DescriptionA noninvasive treatment that applies infrared light to the skin using a flexible infrared-emitting pad containing superluminous gallium aluminum arsenide diodes (emitting around 890 nanometers).

Mechanism claimed by manufacturerIncreases circulation and reduces pain by increasing release of nitric oxide.

Typical applicationPad placed over affected area to stimulate blood flow, reduce inflammation, and promote healing at the treatment site.

ManufacturerAnodyne Therapy System developed by Integrated Systems Physiology Inc.

Monochromatic Phototherapy / LLLT / MIRE / Anodyne — definition and studied indications

Policy Summary

Payerpriority health

PolicyMonochromatic Phototherapy (Anodyne/MIRE/Low-Level Light Therapy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionIf prior authorization is required by the member's product, submit a request demonstrating medical necessity per the Priority Health Provider Manual.

SourceLink

On This Page

Denial Risk

Not Covered Codes — Denial Risk

Not covered codes listed below may result in claim denial if billed for covered services. Providers should not bill these codes when submitting claims for treatments described as investigational or not covered.

0552T – Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies.
1011T – Photobiomodulation (PBM) therapy of oral cavity, including placement/removal of oral device and monitoring.
97026 – Application of a modality; infrared.
A4639 – Replacement pad for infrared heating pad system.
E0221 – Infrared heating pad system.
S8948 – Application of a modality (requiring constant provider attendance); low-level laser; each 15 minutes

Documentation Required

Prior Authorization and Documentation

Prior authorization and documentation requirements: when prior authorization is required by the member's plan, providers must submit documentation that demonstrates medical necessity consistent with Priority Health rules and the Provider Manual. Failure to provide required documentation may result in denial.

Include clinical rationale, relevant history, prior treatments tried, and objective findings when submitting a request.
Follow documentation instructions in the Priority Health Provider Manual for prior authorization submission.

Note

Documentation and Eligibility Note

Providers are responsible for verifying eligibility, benefits, and prior authorization requirements for each member. This section is for informational purposes only and does not supersede the member’s plan terms, eligibility rules, or contract provisions.

Coverage and payment are subject to the member’s plan terms, eligibility on the date of service, and any other applicable policy conditions.

ScopeTherapies using monochromatic infrared or low-level laser/light energy applied to tissue (includes MIRE, Anodyne, low-level laser/photobiomodulation).

Wavelength/exampleCommonly around 890 nanometers for MIRE devices; uses infrared spectrum light sources.

Clinical indications studiedExamples include diabetic peripheral neuropathy and other peripheral neuropathies, cutaneous ulcers/wounds, lymphedema, knee osteoarthritis, and soft-tissue/musculoskeletal pain (e.g., temporomandibular disorders, tendonitis, capsulitis, myofascial pain).

Evidence summarySystematic reviews and randomized trials have been conducted, but meta-analyses conclude evidence is insufficient or inconsistent to support use for chronic non-healing wounds and other indications; some trials report short-term sensory improvements but not sustained neuropathic pain relief.

Examples of study types citedRandomized, double-blind, sham-controlled trials and systematic reviews/meta-analyses addressing neuropathy, knee osteoarthritis, and wound healing.