Description Low Level Laser Therapy

Low level laser therapy (LLLT), also known as cold laser or photobiomodulation therapy, refers to a wide variety of procedures involving several laser types and treatment methods. LLLT uses red beam or near infrared nonthermal lasers. When applied, the lasers penetrate the surface of the skin without a heating (burning) effect, produce no sensation and do not damage the skin. Purportedly due to the low skin absorption and no side effects, the laser light can penetrate deeply into tissues and reach the site of damage or injury.

LLLT may be administered by a physician, physical therapist, occupational therapist or Doctor of Chiropractic (DC) in a provider's office or other outpatient setting and requires no sedation or anesthesia. It is theorized that LLLT may cause a biostimulatory healing effect for the treatment of a range of conditions, including:

• alopecia,
• arthritis,
• carpal tunnel syndrome,
• chronic pain,
• prevention of oral mucositis,
• temporomandibular joint disorders,
• tissue injuries (e.g., tendinopathy, tendinitis)
• wound healing.

These devices are not the same as (or equivalent to) class IV surgical lasers.

Examples of LLLT devices include, but may not be limited to:

• Bioptron 2,
• Bioptron MedAll,
• Bioptron Pro 1,
• Erchonia EVRL,
• Erchonia FX-635,
• Luminex Laser Therapy System,
• MicroLight ML830,
• RianCorp LTU-904,
• TerraQuant,
• Thor Laser System
• Willow Curve.

The TerraQuant device uses a combination of a super pulsed laser, pulsed infrared, red light and static magnetic field, which is purported to accelerate pain relief. The Willow Curve primarily uses dual dynamic photonic and dynamic thermokinetic energies proposed for treating musculoskeletal pain.

High Power Laser Therapy

High power laser therapy devices, also referred to as high dose laser therapy (HDLT) or high intensity laser therapy (HILT), (class IV therapeutic lasers) are purported to stimulate accelerated healing energy from superficial to deep levels (six to nine inches) over a larger surface treatment area. It is proposed for treating conditions such as arthritis, carpal tunnel syndrome, chronic pain, epicondylitis, sprains/strains, trigger points and various other musculoskeletal disorders. These devices are not the same as (or equivalent to) class IV surgical lasers.

Examples of high power laser therapy devices that have received US Food & Drug Administration (FDA) approval are:

• AVI HP-7.5,
• AVI HPLL-12,
• Diowave Laser System.

Coverage Determination

Humana members may be eligible under the Plan for LLLT (cold laser therapy, photobiomodulation) for prevention of oral mucositis in an individual with cancer for the following indications:

• Receiving head and neck radiation therapy (RT) with chemotherapy; OR
• Receiving head and neck RT without chemotherapy; OR
• Undergone hematopoietic stem cell transplantation (HSCT)

Low Level Laser and High Power Laser Therapy Effective Date: 05/25/2023

Revision Date: 05/25/2023

Review Date: 05/25/2023

Policy Number: HUM-0354-017

Page: 3 of 7

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Humana members may NOT be eligible under the Plan for LLLT (cold laser therapy, photobiomodulation) OR high power laser therapy (nonsurgical) for any indications other than those listed above. This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about arthritis, carpal tunnel syndrome, musculoskeletal disorders and wounds may be found from the following websites:

Background

• American Academy of Orthopaedic Surgeons
• American Diabetes Association
• Arthritis Foundation
• National Library of Medicine
• National Pressure Injury Advisory Panel

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.