CurrentRegence BlueCross BlueShieldPolicy 105

Low-Level Laser Therapy

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This policy governs coverage of low-level laser therapy, also called photobiomodulation, including its use for preventing oral mucositis during cancer treatment. Coverage applies when the device is FDA-approved and the treatment is requested for individuals at increased risk of oral mucositis from chemotherapy, radiotherapy, or hematopoietic cell transplantation.

Policy Summary

PayerRegence BlueCross BlueShield

PolicyLow-Level Laser Therapy

Policy CodePolicy 105

Change TypeNo material change

Effective DateOctober 1, 2026

Last ReviewJun 1, 2026

Next Review DateJune 1, 2027

Key ActionSubmit clinical notes, current symptoms and indication, the device manufacturer and model, and documentation supporting prevention of oral mucositis in a high-risk patient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Required medical-necessity criteria

FDA-approvedDevice requirement for coverage

Oral mucositis preventionCovered clinical indication

2Primary coverage settings

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CurrentRegence BlueCross BlueShieldPolicy 105

Low-Level Laser Therapy

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Sign up for regence Policy 105 alerts

Get alerted when Policy 105 changes without checking for updates manually.

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Policy Summary

PayerRegence BlueCross BlueShield

PolicyLow-Level Laser Therapy

Policy CodePolicy 105

Change TypeNo material change

Effective DateOctober 1, 2026

Last ReviewJun 1, 2026

Next Review DateJune 1, 2027

Key ActionSubmit clinical notes, current symptoms and indication, the device manufacturer and model, and documentation supporting prevention of oral mucositis in a high-risk patient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Required medical-necessity criteria

FDA-approvedDevice requirement for coverage

Oral mucositis preventionCovered clinical indication

2Primary coverage settings

5Listed treatment protocols

Coverage Criteria

Medically Necessary

Low-level laser therapy may be considered medically necessary when ALL of the following criteria are met:

ALL of the following

The device is FDA-approved.
The request is for prevention of oral mucositis in an individual undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy and/or radiotherapy, and/or hematopoietic cell transplantation.

Investigational

Low-level laser therapy is considered investigational when Criterion I is not met.

Criterion I for medically necessary coverage is not met.

Prevention of Oral Mucositis

Low-level laser therapy may be considered medically necessary for prevention of oral mucositis when ALL of the following criteria are met:

ALL of the following

The device is FDA-approved.
The individual is undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy and/or radiotherapy, and/or hematopoietic cell transplantation.

Investigational Uses

Low-level laser therapy is investigational for uses other than prevention of oral mucositis.

{"text":"The requested use is for a condition other than oral mucositis, including but not limited to carpal tunnel syndrome, various musculoskeletal conditions, or wound healing."},{"text":"The requested therapy includes laser acupuncture for a condition other than oral mucositis."}

There is not enough research to show that low-level laser therapy (LLLT), including laser acupuncture, can improve health outcomes for individuals with conditions other than oral mucositis, including but not limited to carpal tunnel syndrome, various musculoskeletal conditions, and wound healing. Therefore, LLLT is investigational for these indications and when the policy criteria for medically necessary coverage are not met.

Coding and Treatment Protocols

CPTCPT

0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional.
0936T	Photobiomodulation therapy of retina, single session.
97039	Unlisted modality (specify type and time if constant attendance).

HCPCSHCPCS

S8948

Application of a modality (requiring constant provider attendance) to one or more areas; low level laser, each 15 minutes.

Pediatric red-light spectrum

Wavelength range620-750 nm

TreatmentIntraoral photobiomodulation therapy

Guideline useRed-light spectrum for prevention of oral and oropharyngeal mucositis

HSCT protocol 1

Wavelength632.8 nm

Irradiance31.25 mW/cm2

Time per spot40 seconds

Provider Documentation and Coverage Risks

Documentation Required

Required Clinical Documentation

Submit the clinical and device information needed for review; missing information may affect the coverage determination.

History and physical and/or chart notes
Current symptomology and treatment indication
Manufacturer and model name of the device
Documentation that treatment is needed to prevent oral mucositis in an individual with cancer at high risk because of cancer treatment

Denial Risk

Criteria Not Met: Device or Indication

Coverage may be denied when the requested low-level laser therapy does not satisfy both policy requirements: use of an FDA-approved device and prevention of oral mucositis in an individual undergoing qualifying cancer treatment or hematopoietic cell transplantation.

Background

Low-level laser therapy (LLLT), also called photobiomodulation, uses red or near-infrared laser light at substantially lower intensity than surgical lasers. Typical devices use wavelengths of approximately 600–1000 nm and power of 5–500 mW. Although the therapy has been proposed for numerous conditions, this policy identifies medical necessity specifically for prevention of oral mucositis in high-risk individuals undergoing cancer treatment.

Definitions and Abbreviations

Low-level laser therapy

DefinitionA therapy using red-beam or near-infrared laser light at much lower intensity than surgical lasers

Typical wavelength600-1000 nm

Typical power5-500 milliwatts

Photobiomodulation

DefinitionApplication of low-intensity red or near-infrared laser energy

Relationship to LLLTPhotobiomodulation is another name for low-level laser therapy

Typical wavelength600-1000 nm

Policy Summary

PayerRegence BlueCross BlueShield

PolicyLow-Level Laser Therapy

Policy CodePolicy 105

Change TypeNo material change

Effective DateOctober 1, 2026

Last ReviewJun 1, 2026

Next Review DateJune 1, 2027

Key ActionSubmit clinical notes, current symptoms and indication, the device manufacturer and model, and documentation supporting prevention of oral mucositis in a high-risk patient.

SourceLink

On This Page

Sites and duration18 sites; from the day after cessation of conditioning for 5 days

HSCT protocol 2

Wavelength650 nm

Irradiance1000 mW/cm2

Time per spot2 seconds

Fluence2.0 J/cm2

Spot size0.04

Sites and duration54-70 sites; from the first day of conditioning to day +2 post-HSCT for 7-13 days

RT protocol

Wavelength632.8 nm

Irradiance24 mW/cm2

Time per spot125 seconds

Fluence3.0 J/cm2

Spot size1.00

Sites and duration12 sites; entire radiotherapy course

RT-CT protocol 1

Wavelength660 nm

Irradiance417 mW/cm2

Time per spot10 seconds

Fluence4.2 J/cm2

Spot size0.24

Sites and duration72 sites; entire radiotherapy course

RT-CT protocol 2

Wavelength660 nm

Irradiance625 mW/cm2

Time per spot10 seconds

Fluence6.2 J/cm2

Spot size0.04

Sites and duration69 sites; entire radiotherapy course

The device must be FDA-approved.
The request must be for prevention of oral mucositis associated with chemotherapy, radiotherapy, and/or hematopoietic cell transplantation.
Requests that do not meet both criteria are not medically necessary under this policy.

Denial Risk

Non-Mucositis Indications

Low-level laser therapy, including laser acupuncture, is investigational for conditions other than oral mucositis, regardless of the specific non-mucositis indication.

Examples include carpal tunnel syndrome, various musculoskeletal conditions, and wound healing.
Do not submit non-mucositis uses as covered prevention of oral mucositis.

Denial Risk

Coverage Requirements Must Be Met

Coverage may be denied if the treatment request does not meet the policy’s required clinical indication and device requirements for oral mucositis prevention.

The patient must have increased risk of oral mucositis from qualifying cancer treatment and/or hematopoietic cell transplantation.
The device used must be FDA-approved.
The request must be for prevention of oral mucositis, not treatment of another condition.

Denial Risk

Policy Criteria Not Met

Low-level laser therapy is investigational when the policy criteria are not met. Providers should verify the device approval, treatment indication, and qualifying cancer-treatment context before submitting a request.

Failure to satisfy the policy criteria results in investigational status.
Investigational services may not qualify for coverage.

Laser acupuncture

DefinitionApplication of low-level laser energy to acupuncture points on the body

Energy typeLow-level laser energy

Application siteAcupuncture points on the body

Aphthous stomatitis

DefinitionA condition evaluated in studies of low-level laser therapy

Alternate termCanker sores

Reported study outcomesPain relief, duration of wound healing, and reduction in frequency of episodes

Photobiomodulation therapy (PBM)

DefinitionIntraoral photobiomodulation therapy using low-level laser therapy for prevention of oral mucositis

HSCT applicationPrevention of oral mucositis associated with hematopoietic stem-cell transplantation

Protocol requirementFollow the specific photobiomodulation therapy parameters of the selected protocol

HSCT

AbbreviationHSCT

MeaningHematopoietic stem-cell transplantation

Clinical contextA cancer-treatment setting addressed in intraoral photobiomodulation protocols

AbbreviationCT

MeaningChemotherapy

Clinical contextCancer treatment used in RT-CT protocols and high-dose conditioning

AbbreviationRT

MeaningRadiotherapy

Clinical contextCancer treatment addressed in the radiotherapy and RT-CT protocols

AbbreviationOM

MeaningOral mucositis

Treatment purposePrevention during cancer therapy

LLLT

AbbreviationLLLT

MeaningLow-level laser therapy

Included applicationLaser acupuncture

Photobiomodulation therapy

DefinitionPhotobiomodulation therapy of the oral cavity

Procedure componentPlacement of an oral device

Patient managementMonitoring of patient tolerance to treatment and removal of the oral device