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Low-Level Laser Therapy Form

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Low-Level Laser Therapy

Indications

(1) Does the request meet this criterion: Carpal tunnel syndrome? 
(2) Does the request meet this criterion: Subacromial impingement? 
(3) Does the request meet this criterion: Adhesive capsulitis? 
(4) Does the request meet this criterion: Temporomandibular joint pain? 
(5) Does the request meet this criterion: Low back pain? 

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 03|01|2026 POLICY LAST UPDATED: 11|05|2025 OVERVIEW Low-level laser therapy (LLLT), also called photobiomodulation, is being evaluated to treat various conditions including oral mucositis, myofascial pain, joint pain, lymphedema, and chronic wounds. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Low-level laser therapy is covered for prevention of oral mucositis in patients undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy and/or radiotherapy, and/or hematopoietic stem cell transplantation. Low-level laser therapy is not covered for all other indications, as the evidence is insufficient to determine the effects of the technology on health outcomes, including but not limited to: • Carpal tunnel syndrome • Neck pain • Subacromial impingement • Adhesive capsulitis • Temporomandibular joint pain • Low back pain • Osteoarthritic knee pain • Heel pain (ie, Achilles tendinopathy, plantar fasciitis) • Rheumatoid arthritis • Bell palsy • Fibromyalgia • Wound healing • Lymphedema Commercial Products Low-level laser therapy is covered for prevention of oral mucositis in patients undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy and/or radiotherapy, and/or hematopoietic stem cell transplantation. Low-level laser therapy is not medically necessary for all other indications, as the evidence is insufficient to determine the effects of the technology on health outcomes, including but not limited to: • Carpal tunnel syndrome • Neck pain • Subacromial impingement • Adhesive capsulitis DRAFT Medical Coverage Policy | Low-Level Laser Therapy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• Temporomandibular joint pain • Low back pain • Osteoarthritic knee pain • Heel pain (ie, Achilles tendinopathy, plantar fasciitis) • Rheumatoid arthritis • Bell palsy • Fibromyalgia • Wound healing • Lymphedema

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.

BACKGROUND Low-level laser therapy (LLLT) refers to the use of red-beam or near-infrared lasers with a wavelength between 600 and 1000 nm and power between 5 and 500 MW. In contrast, lasers used in surgery typically use 300 Watts. When applied to the skin, LLLT produces no sensation and does not burn the skin. Because of the low absorption by human skin, it is hypothesized that the laser light can penetrate deeply into the tissues where it has a photobiostimulative effect. The exact mechanism of its effect on tissue healing is unknown; hypotheses have included improved cellular repair and stimulation of the immune, lymphatic, and vascular systems. LLLT is being evaluated to treat a wide variety of conditions, including soft tissue injuries, myofascial pain, tendinopathies, nerve injuries, and joint pain. LLLT has also been evaluated for lymphedema.

Oral Mucositis Oral mucositis describes inflammation of the oral mucosa and typically manifests as erythema or ulcerations that appear 7 to 10 days after initiation of high-dose cancer therapy. Oral mucositis can cause significant pain and increased risk of systemic infection, dependency on total parenteral nutrition, and use of opioid analgesics.

Treatment Treatment planning may also need to be modified due to dose-limiting toxicity. There are a number of interventions for oral mucositis that may partially control symptoms, but none is considered a criterion standard treatment. When uncomplicated by infection, oral mucositis is self-limited and usually heals within 2 to 4 weeks after cessation of cytotoxic chemotherapy. Low-level laser therapy (LLLT) has been used in cancer therapy‒induced oral mucositis in patients treated with radiotherapy and/or chemotherapy and hematopoietic cell transplantation.

Musculoskeletal and Neurologic Disorders Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and the most commonly performed surgery of the hand. The syndrome is related to the bony anatomy of the wrist. The carpal tunnel is bound dorsally and laterally by the carpal bones and ventrally by the transverse carpal ligament. Through this contained space run the 9 flexor tendons and the median nerve. Therefore, any space-occupying lesion can compress the median nerve and produce the typical symptoms of CTS - pain, numbness, and tingling in the distribution of the median nerve. Symptoms of more severe cases include hypesthesia, clumsiness, loss of dexterity, and weakness of pinch. In the most severe cases, patients experience marked sensory loss and significant functional impairment with thenar atrophy.

Treatment Mild-to-moderate cases of CTS are usually first treated conservatively with splinting and cessation of aggravating activities. Other conservative therapies include oral steroids, diuretics, nonsteroidal anti- inflammatory drugs, and steroid injections into the carpal tunnel itself. Patients who do not respond to conservative therapy or who present with severe CTS with thenar atrophy may be considered candidates for

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

surgical release of the carpal ligament, using either an open or endoscopic approach. LLLT is also used to treat CTS.

Wound Care and Lymphedema Chronic wounds are wounds that do not improve after 4 weeks or heal within 8 weeks. These include diabetic foot ulcers, venous-related ulcerations, non-healing surgical wounds, and pressure ulcers. They are often found on the feet, ankles, heels, and calves, and on the hips, thighs, and buttocks of those who cannot walk. Lymphedema is described as swelling in at least 1 leg and/or arm. It is commonly caused by the removal of a lymph node. The resulting blockage of the lymphatic system prevents lymph fluid from draining well, leading to fluid build-up and swelling. Other symptoms can include heaviness or tightness in the affected limb, restricted range of motion, aching or discomfort, recurring infections, and dermal fibrosis. Risk factors for developing lymphedema after cancer from cancer treatment or from other secondary causes can include older age, obesity, and rheumatoid or psoriatic arthritis.

Treatment Chronic wound management involves ensuring adequate blood flow to the area, preventing the wound from drying, controlling infections, debriding scarred and necrotic tissue, and managing pain. The standard of care for diabetic foot ulcers includes debridement, dressings, offloading of pressure, infection management, and glycemic control. Lymphedema is typically managed with pneumatic compression, exercise, or complete decompression therapy. Use of LLLT has been investigated for the management of both chronic wounds and lymphedema.

For individuals who have increased risk of oral mucositis due to some cancer treatments (eg, chemotherapy, radiotherapy) and/or hematopoietic cell transplantation who receive LLLT, the evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

The evidence for LLLT is insufficient to determine the effects of the technology on health outcomes in individuals who have the following conditions: • orthopedic pain (ie, neck pain, osteoarthritic knee pain, low back pain, carpal tunnel syndrome) • shoulder conditions (eg, subacromial impingement syndrome, adhesive capsulitis), heel pain, or temporomandibular joint pain • bone, ligament, and joint conditions (eg, rheumatoid arthritis, fibromyalgia) • Bell’s palsy • lymphedema • chronic non-healing wounds

CODING Medicare Advantage Plans and Commercial Products The following code(s) are covered when filed with the ICD-10 CM Diagnosis* codes below: 0552T Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a
physician or other qualified health care professional 97037 Application of a modality to 1 or more areas; low-level laser therapy (ie, nonthermal and non
ablative) for post-operative pain reduction S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level

laser; each 15 minutes

*ICD-10 CM Diagnosis Codes:
C00 - D49 K12.30-K12.39

RELATED POLICIES Not applicable

PUBLISHED

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, January 2026
Provider Update, December 2025 Provider Update, November 2024 Provider Update, August 2023 Provider Update, September 2022

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 7 (401) 274-4848 WWW.BCBSRI.COM

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