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Medical Policy: 01.01.08
Original Effective Date: October 2003
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Monochromatic infrared energy (MIRE) refers to light at a wavelength of 880 nm. MIRE can be delivered through pads containing an array of superluminous infrared diodes emitting pulsed near-infrared irradiation. The pads can be placed on the skin and the infrared energy is delivered in a session lasting from 30-45 minutes. The Anodyne® Therapy System is a MIRE device that received marketing clearance through the U.S. Food and Drug Administration (FDA) in 1994. MIRE devices have been investigated as a treatment of multiple conditions including cutaneous ulcers, diabetic neuropathy, musculoskeletal and soft tissue injuries, and myofascial pain. The proposed mechanism of action is unknown.
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Prior Approval:
Not applicable
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Policy:
Skin contact monochromatic infrared energy is considered investigational as a technology to treat chronic, non-healing cutaneous ulcers, diabetic neuropathy, peripheral neuropathy and miscellaneous musculoskeletal disorders because it has not been adequately demonstrated to have any significant therapeutic effect. Benefits are not available for the infrared light system and any related accessories.
The available literature regarding skin contact MIRE as a technique to treat various conditions is inadequate to draw clinical conclusions. This technology is considered investigational given the insufficient evidence to evaluate the impact on net health outcome.
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Procedure Codes and Billing Guidelines:
- To report provider services use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 diagnostic codes.
- E0221 Infrared heating pad system
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Selected References:
- Kochman AB, Carnegie DH, Burke TJ. Symptomatic Reversal of Peripheral Neuropathy in Patients with Diabetes. Journal of the American Podiatric Medical Association 92(3) 2002.
- Thomasson TL, Effects of Skin-Contact Monochromatic Infrared Irradiation on Tendonitis, Capsulitis, and Myofascial Pain. J Neurol Orthop Med Surg (1996) 16:242-245.
- Noble JG, Lowe AS, Baxter GD. Monochromatic infrared irradiation (890nm): effect of a multi-source array upon conduction in the human median nerve. J Clin Laser Med Surg. 2001 Dec; 19(6):291-5.
- Glascow PD, Hill ID, McKevitt AM, Lowe AS, Baxter D. Low intensity monochromatic infrared therapy: a preliminary study of the effects of a novel treatment unit upon experimental muscle soreness. Lasers Surg Med. 2001;28(1):33-9.
- Leonard DR, Farooqi MH, Myers S. Restoration of sensation, reduced pain, and improved balance in subjects with diabetic peripheral neuropathy: a double-blind, randomized, placebo-controlled study with monochromatic near-infrared treatment. Diabetes Care. 2004 Jan;27(1):168-72.
- ECRI, HTAIS, Monochromatic Infrared Irradiation for the treatment of Peripheral Neuropathy, December 2004.
- Clifft JK, Kasser RJ, Newton TS, Bush AJ, The effect of monochromatic infrared energy on sensation in patients with diabetic peripheral neuropathy: a double-blind, placebo-controlled study. Diabetes Care. 2005 Dec; 28(12):2896-900.
- ECRI, HTAIS. TARGET database. Monochromatic infrared irradiation for peripheral neuropathic pain. November 2006.
- Lavery LA, Murdoch DP, Williams J, Lavery DC. Does Anodyne Light Therapy Improve Peripheral Neuropathy in Diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy. Diabetes Care. 2008 Feb;31(2):316-21.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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