Monochromatic Infrared Energy for Wound Healing and Peripheral Neuropathy

Medical Policy: 01.01.08 
Original Effective Date: October 2003 
Reviewed: August 2008 
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

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.


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Procedure Codes and Billing Guidelines: 

  • To report provider services use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 diagnostic codes.
  • HCPCS code E0221 Infrared heating pad system 

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Selected References: 

  • A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
  • 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. 

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.