LOW-LEVEL LASER THERAPY AND DEEP TISSUE ... - …

1 Status Active Medical and Behavioral Health Policy Section: Medicine Policy Number: II-09 Effective Date: 01/22/2014 Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are responsible for medical advice and treatment of patients. Members with specific health care needs should consult an appropriate health care professional. LOW-LEVEL LASER THERAPY AND DEEP TISSUE LASER THERAPY Description: LOW-LEVEL LASER THERAPY (examples include, but are not limited to, cold LASER THERAPY , low-energy LASER THERAPY , class III LASER THERAPY , and LASER acupuncture when applied to acupuncture points), refers to the use of LASER intensities that induce minimal, if any, temperature elevations. LOW-LEVEL LASER light is compressed light of a wavelength from the cold, red part of the spectrum of electromagnetic radiation.

2 The light travels in a straight line, is monochromatic, and is polarized which allows its beam to be concentrated in a defined location or spot. These properties, in theory, allow LASER light from the hand-held, battery-operated lasers to penetrate the skin with no heating effect, no damage to the skin, and no known side effects. In general, LOW-LEVEL LASER THERAPY (LLLT) includes red-beam or near-infrared lasers with a wavelength between 600 and 1000nm and LASER powers from 5-500 milliWatts. LOW-LEVEL LASER THERAPY has been proposed for the treatment of a variety of conditions including carpal tunnel syndrome, musculoskeletal disorders and sport injuries, whiplash injuries, arthritis, pain, chronic wounds, tinnitus, autoimmune diseases, migraines, disc herniations, heavy metal detoxification, smoking addiction, hair loss, and tuberculosis. A number of LOW-LEVEL lasers have received clearance for marketing from the Food and Drug Administration (FDA) for pain indications.

3 These include: the MicroLight 830 LASER , the GRT LITE , the Tuco Erchonia PL3000, the Excalibur System, the Acculaser Pro, and the LightStream Low Level LASER . Although a LOW-LEVEL LASER device is also being marketed for treatment of smoking addiction ( , Breathe Today LASER THERAPY ), no devices have received FDA clearance for applications other than treatment of pain. Deep TISSUE LASER THERAPY (examples include, but are not limited to, class IV LASER THERAPY or high-power LASER THERAPY ) provides LASER power output from 500 up to 7500 milliWatts. Because these hand-held devices provide more power than LOW-LEVEL lasers, they theoretically provide deeper penetration in less time over a larger surface treatment area. Deep TISSUE LASER THERAPY has been proposed for use in the office setting to provide topical heating for the purpose of elevating TISSUE temperature for relief of a number of musculoskeletal conditions including low back pain, carpal tunnel syndrome, epicondylitis (tennis elbow), arthritis conditions, headaches, and plantar fasciitis.

4 This type of class IV LASER is not be confused with class IV surgical lasers. Examples of LASER devices used in deep TISSUE LASER THERAPY include: LCT-1000 (LiteCure, LLC), K- LASER (K- LASER , USA), and ALT LASER (Avicenna LASER Technology, Inc). NOTE: Separate medical policies exist for LASER THERAPY for skin conditions: Phototherapy for the Treatment for Psoriasis, II-39 Non Pharmacologic Treatment of Acne, II-33 Non Pharmacologic Treatment of Rosacea, II-08 Policy: The use of LOW-LEVEL LASER THERAPY and deep TISSUE LASER THERAPY is considered INVESTIGATIVE for all indications, due to the lack of clinical evidence demonstrating its impact on improved health outcomes. Coverage: Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. Medicaid products and some self-insured plans may have additional policies and prior authorization requirements.

5 Receipt of benefits is subject to all terms and conditions of the member s summary plan description (SPD). As applicable, review the provisions relating to a specific coverage determination, including exclusions and limitations. Blue Cross reserves the right to revise, update and/or add to its medical policies at any time without notice. For Medicare NCD and/or Medicare LCD, please consult CMS or National Government Services websites. Refer to the Pre-Certification/Pre-Authorization section of the Medical Behavioral Health Policy Manual for the full list of services, procedures, prescription drugs, and medical devices that require Pre-certification/Pre-Authorization. Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met. Coding: The following codes are included below for informational purposes only, and are subject to change without notice.

6 Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. HCPCS: S8948 Application of a modality (requiring constant provider attendance) to one or more areas; LOW-LEVEL LASER ; each 15 minutes Policy History: Developed September 8, 2004 Most recent history: Reviewed February 9, 2011 Reviewed February 8, 2012 Reviewed February 13, 2013 Reviewed January 8, 2014 Cross Reference: Acupuncture, III-01 Phototherapy for the Treatment for Psoriasis, II-39 Non Pharmacologic Treatment of Acne, II-33 Non Pharmacologic Treatment of Rosacea, II-08 Tobacco Cessation Treatments, X-21 Current Procedural Terminology (CPT ) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

7 Copyright 2014 Blue Cross Blue Shield of Minnesota.