Medical Policy: 02.01.14
Original Effective Date: March 2003
Reviewed: February 2016
Revised: December 2015
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:
Low-level laser therapy, also known as cold laser therapy and sometimes called class III lasers, has been investigated as a conservative measure to treat a number of musculoskeletal disorders, soft tissue injuries including carpal tunnel syndrome (CTS) and other disorders such as Raynaud's disease and fibromyalgia. When applied to the skin, it has been hypothesized that the laser light penetrates the skin and stimulates cellular metabolism leading to temporary relief of hand and wrist pain. The exact mechanism of its effect is unknown.
CTS is perhaps the most studied application of this type of laser therapy. CTS is an entrapment neuropathy caused by compression of the median nerve as it passes from the forearm to the palm beneath the transverse carpal ligament. Associated signs and symptoms include paresthesias; numbness and tingling in the sensory distribution of the median nerve for thumb, index, middle and radial side of the ring finger; Tinel sign; Plalen sign; nocturnal awakening; and sometimes hand weakness. The etiology of CTS is unknown; however, it occurs most commonly in workers involved in repetitive hand movements. Current standard treatments include conservative measures such as wrist splints and non-steroidal antiinflammatory drugs. Surgical release of the transverse carpal ligament may be performed when symptoms fail to respond to conservative measures.
Recently the use of higher powered, also non-surgical, lasers have been used for the treatment of the above mentioned musculoskeletal conditions, specifically peripheral neuropathy pain treatment. Sometimes these are referred to as Class IV lasers.
In November 2010, the BlueCross BlueShield Association Technology Evaluation Center (TEC) published a technology assessment of low-level laser therapy for carpal tunnel syndrome and chronic neck pain. For inclusion in the assessment studies had to: be published in a peer-reviewed journal; be randomized, sham-controlled trials and, if adjunctive therapies were used, they were applied to both groups; measure outcomes at least 2 weeks beyond the end of the treatment period; and, for neck pain studies, be studies of patients with chronic pain.
Four studies of carpal tunnel syndrome met the inclusion criteria. TEC concluded that the studies have serious limitations including limited follow-up, and no one study is so methodologically sound as to provide definitive results.
The TEC assessment included 6 trials of low-level laser therapy for chronic neck pain and found inconsistent results. The TEC assessment did comment on a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials by Chow and colleagues and noted "some studied evaluated acute neck pain, some had insufficient follow-up beyond the period of treatment, one had no sham control…." Overall, TEC concluded that the studies are characterized by small sample sizes, limited statistical power, and limited long-term follow-up.
Prior Approval:
Not applicable
Policy:
Low-level laser treatment or cold laser treatment is considered investigational for carpal tunnel syndrome, chronic neck pain, mucosititis and all other applications.
High-powered, non-surgical lasers are considered investigational for peripheral neuropathy and all other applications.
The available literature on low-level laser therapy as a treatment for pain of various etiologies and in a variety of anatomical sites presents inconsistent conclusions and methodologic weaknesses including a lack of follow-up evaluation, that prevent drawing firm conclusions regarding efficacy.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 97039 Unlisted modality (specify type and time if constant attendance)
- 97139 Unlisted therapeutic procedure (specify)
- 99199 Unlisted special service, procedure or report
- S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low level laser; each 15 minutes.
Selected References:
- Bronco K, Naeser MA. Carpal tunnel syndrome: Clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies-an open protocol study. The Journal of Alternative and Complementary Medicine1999;5(1):5-26.
- Irvine J, Chong SL, Amirjani N, Chan KM. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve 2004 Aug;30(2):182-7.
- Zinman LH, Ngo M, Ng ET, Nwe KT, Gogov S, Bril V. Low-intensity laser therapy for painful symptoms of diabetic sensorimotor polyneuropathy: a controlled trial. Diabetes Care. 2004 Apr;27(4):921-4.
- Brosseau L, Wells G, et al. Randomized controlled trial on low level laser therapy (LLLT) in the treatment of osteoarthritis (OA) of the hand. Lasers Surg Med. 2005 Mar;36(3):210-9.
- Bjordal JM, Lopes-Martins RA, Iversen VV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med. 2006 Jan;40(1):76-80; discussion 76-80.
- Savigny P, Kuntze S, Watson P et al. Low back pain: early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care and Royal College of General Practitioners.
- Dincer U, Cakar E, Kiralp MZ et al. The effectiveness of conservative treatments of carpal tunnel syndrome: splinting, ultrasound, and low-level laser therapies. Photomed Laser Surg 2009 Jan 26. [Epub ahead of print].
- Yousefi-Nooraie R, Schonstein E, Heidari K et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev 2008; (2):CD005107.
- Yeldan I, Cetin E, Ozdincler AR. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Disabil Rehabil 2009; 31(11):935-40.
- Tumilty S, Munn J, McDonough S et al. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg 2009 Aug 26. [Epub ahead of print].
- Chow RT, Heller GZ, Barnsley L. The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain. 2006 Sep;124(1-2):201-10. Epub 2006 Jun 27.
- Ay S, Dogan SK, Evcik D. Is low-level laser therapy effective in acute or chronic low back pain? Clin Rheumatol. 2010 Aug;29(8):905-10. Epub 2010 Apr 23.
- Gur A, Sarac AJ, Cevik R et al. Efficacy of 904 nm gallium arsenide low level laser therapy in the management of chronic myofascial pain in the neck: a double-blind and randomized-controlled trial. Lasers Surg Med. 2004;35(3):229-35.
- Altan L, Bingol U, Aykac M et al. Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome. Rheumatol Int. 2005 Jan;2591):23-7. Epub 2003 Dec 12.
- Konstantinovic LM, Cutovic MR, Milovanovic AN et al. Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Pain Med. 2010 Aug;11(8):1169-78.
- Fulop AM, Dhimmer S, Deluca JR et al. A meta-analysis of the efficacy of laser phototherapy on pain relief. Clin J Pain 2010 Oct;26(8):729-36.
- Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010 Jun;10(6):514-29.
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Low-level laser therapy for carpal tunnel and chronic neck pain. TEC Assessments 2010; Volume 25, Tab 4.
- Omar MTA, Ebid AA, El Morsy AM. Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. J Surg Res 2011; 165(1):82-90.
- Alfredo PP, Bjordal JM, Dreyer SH, Meneses SR, Zaguetti G, Ovanessian V, et al. Efficacy of low level laser therapy associated with exercises in knee osteoarthritis: a randomized double-blind study. Clin Rehabil. 2012 Jun;26(6):523-33.
- American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Treatment of Carpal Tunnel Syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008. Guidelines re-issue statement September 2011. Accessed May 29, 2012.
- Carvalho PA, Jaguar GC, Pellizzon AC, Prado JD, Lopes RN, Alves FA. Evaluation of low-level laser therapy in the prevention and treatment of radiation-induced mucositis: a double-blind randomized study in head and neck cancer patients. Oral Oncol. 2011 Dec;47(12):1176-81.
- Petrucci A, Sgolastra F, Gatto R, Mattei A, Monaco A. Effectiveness of low-level laser therapy in temporomandibular disorders: a systematic review and meta-analysis. J Orofac Pain. 2011 Fall;25(4):298-307.
- Savigny P, Kuntze S, Watson P, et al. Low back pain: early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care and Royal College of General Practitioners. 2009; Low back pain in adults: early managementExternal SiteExternal Site
- Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. May 15 2014;120(10):1453-1461. PMID 24615748
- Chang WD, Lee CL, Lin HY, et al. A Meta-analysis of Clinical Effects of Low-level Laser Therapy on Temporomandibular Joint Pain. J Phys Ther Sci. Aug 2014;26(8):1297-1300. PMID 25202201
Policy History:
- February 2016 - Annual Review, Policy Renewed
- December 2015 - Interim Review, Policy Revised
- March 2015 - Annual Review, Policy Revised
- June 2013 - Annual Review, Policy Renewed
- July 2012 - Annual Review, Policy Renewed
- August 2011 - Annual Review, Policy Renewed
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 © 2012 American Medical Association. All Rights Reserved.