Perhaps you have been using a new laser device, but are experiencing frustration over reimbursement. Sure, cash payments are nice, but may be a barrier for some patients. Is it possible for insurance carriers to pay for laser?
However, not much clinical research exists on this therapy. Even still, as conservative health care providers we should consider alternative pain management strategies, and when used properly, PBM is considered a safe treatment.
Most insurers and payors make coverage decisions based on guidelines and the best available scientific evidence. Some of these decisions made are to deny care. To overcome a denial, you must show the following:
- The guideline the carrier is using is not appropriate for the particular patient.
- The recommended treatment to date has not been effective and you are selecting another effective treatment.
- The patient has comorbidities which may take them outside the guidelines.
- You can provide other high-quality published literature that is more recent or higher quality than the guideline the payor is using to deny your claim.
A Case Example
Consider you are treating a patient who was involved in a motor-vehicle accident one month ago, and has persistent neck and radiating left arm pain. He is more than 50 years old, overweight and has tried aspirin, but this gives him gastric problems.
For the past three weeks, you have done manipulation, physiotherapy, stretching, massage, and have recommended exercise, but the patient says he is unable to do regular activity because he is out of shape. He reports that your therapies have helped, but only to a point, and you are concerned that his neck pain may become chronic.
The patient is apprehensive about trying injections and is asking you what else you can do to help. In this case, you may consider PBM since it has been shown to reduce inflammation and promote healing.
The patient's insurance carrier uses the Official Disability Guidelines (ODG),5 which considers laser therapy for neck pain "under study, with conflicting results,"6 and therefore will likely deny payment. In this case, you are going to have to show that this patient is the exception to the rule and could benefit from PBM.
Tips to Address Payment Denial
To get the care authorized and paid, you will need to provide why the guideline does not apply to this particular patient, and that reasonable alternatives are necessary and appropriate. Here are some helpful tips for this particular patient / case:
The guideline does not apply to this specific patient because of his comorbidities: He is 55, overweight and deconditioned, and cannot tolerate NSAIDs.
The patient has failed three weeks of conservative treatment and does not wish to undergo injections.
Better evidence exists: If the information is from an older guideline, newer and better-quality evidence is available. Additional new evidence that laser therapy might be an effective treatment for patients with neck pain includes:
- PBM has been shown to be effective for chronic pain.7
- A randomized, placebo-controlled trial showed that "LLLT gave more effective short-term relief of arm pain and increased range of neck extension in patients with acute neck pain with radiculopathy in comparison to the placebo procedure."8
- Meta-analyses have reported evidence for laser with neck pain and chronic neck pain patients, and suggested that super-pulsed laser may lead to better outcomes.9-10
Write a letter outlining the history, clinical findings and diagnosis. Include the relevant facts that support the patient being is an exception to the guidelines. Then support your proposed therapy (in this case, PBM) with copies of the relevant literature supporting your decision.
In your letter to the insurance carrier, propose a reasonable trial of care, say 6-12 visits, and use outcome tools such as the Neck Disability Index, numerical pain scale, and functional ability measures (e.g., lifting, work capacity, activities of daily living) to document improvement. These efforts will increase your likelihood of getting reimbursed for PBM therapy.
As part of our ongoing efforts to help translate research into practice, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), also known as the Clinical Compass, is working to translate scientific research into tools that the profession can use to improve clinical practice. There are no guarantees, but you can increase your chance of success.
For more information about other conditions that may be responsive to PBM and how to support the medical necessity of your proposed treatment plan, go to www.ccgpp.com.
References
- Dynamic Chiropractic's Expanding Chiropractic Practice Survey. Executive Summary, October 2016.
- Medical Subject Headings. U.S. National Library of Medicine: https://www.nlm.nih.gov/mesh/.
- Chung H. et al. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng, 2012 Feb;40(2):516-533.
- Prindeze N, Moffatt L, Shupp J. Mechanisms of action for light therapy: a review of molecular interactions. Exper Biol and Med, 2012;237:1241-1248.
- Official Disability Guidelines (2017). Work Loss Data Institute, Corpus Christi, Texas.
- Ibid.
- Kingsley JD, Demcha T, Mathis R. Low-Level laser therapy as a treatment for chronic pain. Front Physiol. 2014;5:306.
- Konstantinovic LM, 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.
- Gross AR, et al. Low level laser therapy (LLLT) for neck pain: a systematic review and meta-regression. Open Orthop J, 2013 Sept. 20;7:396-419.
- Chow RT, et al. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet, 2009 Dec. 5;374(9705):1897-908.
Dr. Wayne Whalen, is a 1986 graduate of Palmer College of Chiropractic West. He is a past president of the California Chiropractic Association and past chairman of the Council on Chiropractic Guidelines and Practice Parameters. He is board certified in chiropractic neurology and was named a Fellow of the International College of Chiropractors.
Dr. Phil Harrington is a certified medical laser safety officer and serves on the subcommittee reviewing the ANSI Standards for Safe Use of Lasers in Health Care Facilities. He is a 1996 Palmer graduate and also holds a bachelor's degree in physics. He is the medical director, clinical manager and laser safety officer for Summus Medical Laser (www.summuslaser.com).