104 Form

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Medical Policy
High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 104 BCBSA Reference Number: 2.01.108 (For Plan internal use only) NCD/LCD: N/A Related Policies
Low Level Laser Therapy, #522 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

High Intensity Laser Therapy (HILT) for treatment of chronic musculoskeletal pain is considered INVESTIGATIONAL.

HILT for treatment of Bell's palsy is considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes

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Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

There is no CPT code for this procedure. Description High Intensity Laser Therapy High-intensity laser therapy (HILT) is a Class IV therapeutic non-surgical laser device with a power output

500 mW that is capable of transmitting energy beyond the skin to deep musculoskeletal tissues.  HILT is proposed for use in the office setting for various indications including musculoskeletal disorders and Bell’s palsy.  The devices are intended to provide temporary relief of muscle spasms and minor muscle/joint pain by emitting energy in the infrared spectrum to provide topical heat and tissue temperature elevation which in turn promotes temporary muscle relaxation and increased local blood circulation.

The mechanism of action of HILT to treat chronic pain or Bell's palsy is not clearly understood. Proposed mechanisms of action include having anti-inflammatory effects through photobiomodulation mechanisms by altering inflammatory markers, photothermal effects leading to improved muscle relaxation and extensibility of connective tissue, or analgesic effects through neural inhibition or endorphin mechanisms.1,

Summary
Description High-intensity laser therapy (HILT) is a Class IV therapeutic non-surgical laser device with a power output 500 mW that is capable of transmitting energy beyond the skin to deep musculoskeletal tissues.  HILT is proposed for use in the office setting for various indications including musculoskeletal disorders and Bell’s palsy. 

Summary of Evidence For individuals who have chronic musculoskeletal pain who receive HILT, the evidence includes randomized clinical trials (RCT) and systematic reviews. Although systematic reviews of RCTs have demonstrated statistically and clinically significant improvements in pain and function in individuals receiving HILT, serious methodological limitations of the trials, along with heterogeneity in HILT parameters, cointerventions, and patient characteristics, decreases confidence in results and precludes drawing conclusions about the treatment's effectiveness. Additionally, there are no established practice guidelines on the use of HILT in chronic pain disorders and it is unclear where the technology fits in the clinical pathway. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have Bell's palsy who receive HILT, the evidence includes 1 RCT (N=48, in 3 groups of 17) comparing HILT, low level laser therapy, and facial expression exercise after 6 weeks of treatment. Significant improvements in recovery were seen in both laser therapy groups over exercise alone, with the greatest improvement seen with HILT, but study design limitations preclude drawing conclusions. Additionally, because Bell's palsy often improves within weeks and may resolve completely within months, it is difficult to isolate specific improvements from laser therapy over the natural resolution of the illness. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 9/2025 Annual policy review. Policy updated with literature search through June 12, 2025; references added. Policy statements unchanged. 12/2024 New medical policy describing investigational indications. Effective 12/1/2024.

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Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Starzec-Proserpio M, Grigol Bardin M, Fradette J, et al. High-Intensity Laser Therapy (HILT) as an Emerging Treatment for Vulvodynia and Chronic Musculoskeletal Pain Disorders: A Systematic Review of Treatment Efficacy. J Clin Med. Jun 27 2022; 11(13). PMID 35806984
2. Food & Drug Administration. Laser Products and Instruments. https://www.fda.gov/radiation-emitting- products/home-business-and-entertainment-products/laser-products-and-instruments. Accessed June 18, 2025.
3. de la Barra Ortiz HA, Arias Avila M, Liebano RE. Quality appraisal of systematic reviews on high- intensity laser therapy for musculoskeletal pain management: an umbrella review. Lasers Med Sci. Dec 09 2024; 39(1): 290. PMID 39652213
4. Ismail Hassan M, Shafiek Mustafa Saleh M, Hesham Sallam M, et al. Extracorporeal Shock Wave Therapy versus laser therapy in treating musculoskeletal disorders: a systematic review and meta- analysis. Lasers Med Sci. Apr 15 2025; 40(1): 194. PMID 40232318
5. Saleh MS, Shahien M, Mortada H, et al. High-intensity versus low-level laser in musculoskeletal disorders. Lasers Med Sci. Jul 11 2024; 39(1): 179. PMID 38990213
6. Khalilizad M, Hosseinzade D, Marzban Abbas Abadi M. Efficacy of High-Intensity and Low-Level Laser Therapy Combined With Exercise Therapy on Pain and Function in Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. J Lasers Med Sci. 2024; 15: e34. PMID 39193110
7. de la Barra Ortiz HA, Parizotto NA, Chamorro Lange C, et al. Effects of high-intensity laser therapy in patients with De Quervain's tenosynovitis: A systematic review and meta-analysis. J Hand Ther. Jan 14 2025. PMID 39814632
8. Yılmaz M, Eroglu S, Dundar U, et al. The effectiveness of high-intensity laser therapy on pain, range of motion, functional capacity, quality of life, and muscle strength in subacromial impingement syndrome: a 3-month follow-up, double-blinded, randomized, placebo-controlled trial. Lasers Med Sci. Feb 2022; 37(1): 241-250. PMID 33400012
9. Yassin M, Parandnia A, Sarrafzadeh J, et al. The effects of high intensity laser therapy and dry needling on clinical signs in females with upper trapezius muscle active trigger points: A single blinded randomized clinical trial. J Bodyw Mov Ther. Oct 2024; 40: 1381-1387. PMID 39593460
10. Qataya PO, Zaki AM, Amin F, et al. Piano level laser therapy versus epidermal growth factor injection for painful myogenic temporomandibular disorder (a randomized clinical trial). Clin Oral Investig. Feb 06 2025; 29(2): 118. PMID 39912963
11. Bilir EE, Atalay SG, Tezen Ö, et al. Comparison of high intensity laser therapy and extracorporeal shock wave in treatment of lateral epicondylitis: a randomized controlled study. Lasers Med Sci. Nov 08 2024; 39(1): 270. PMID 39511042
12. Kim JH, Goo B, Nam SS. Efficacy of Laser Therapy on Paralysis and Disability in Patients with Facial Palsy: A Systematic Review of Randomized Controlled Trials. Healthcare (Basel). Aug 29 2023; 11(17). PMID 37685454
13. Alayat MS, Elsodany AM, El Fiky AA. Efficacy of high and low level laser therapy in the treatment of Bell's palsy: a randomized double blind placebo-controlled trial. Lasers Med Sci. Jan 2014; 29(1): 335-
14. PMID 23709010
15. North American Spine Society (2020). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf . Accessed June 18, 2025.
16. Xie YH, Liao MX, Lam FMH, et al. The effectiveness of high-intensity laser therapy in individuals with neck pain: a systematic review and meta-analysis. Physiotherapy. Dec 2023; 121: 23-36. PMID 37812850

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16. Cai P, Wei X, Wang W, et al. High-intensity laser therapy on pain relief in symptomatic knee osteoarthritis: A systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2023; 36(5): 1011-1021. PMID 37458008
17. de la Barra Ortiz HA, Parizotto N, Arias M, et al. Effectiveness of high-intensity laser therapy in the treatment of patients with frozen shoulder: a systematic review and meta-analysis. Lasers Med Sci. Nov 20 2023; 38(1): 266. PMID 37981583
18. de la Barra Ortiz HA, Arias M, Liebano RE. A systematic review and meta-analysis of randomized controlled trials on the effectiveness of high-intensity laser therapy in the management of neck pain. Lasers Med Sci. May 06 2024; 39(1): 124. PMID 38709332