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Clinical Policy Bulletin:
Laser Neurolysis
Number: 0552


Policy

Aetna considers laser peripheral nerve block (laser neurolysis) experimental and investigational for any indications (e.g., carpal tunnel syndrome, facet or sacroiliac joint pain) because of insufficient evidence regarding its effectiveness.

See also CPB 0363 - Cold Laser and High-Power Laser Therapies.



Background

Laser neurolysis is the non-invasive application of laser to peripheral nerves.  As such, it is a form of low-level laser therapy.

Laser neurolysis has primarly been investigated for treatment of carpal tunnel syndrome.  Weintraub (1997) reported on the results of laser neurolysis in a series of 30 hands of 23 patients with carpal tunnel syndrome.  Subjects had a mean age of 52.4 years and a mean duration of symptoms of 24.4 months.  They had a pre-treatment compound muscle action potential distal latency greater than 4.0 milliseconds (ms) and sensory nerve action potential greater than 3.7 ms.  Patients underwent 15 treatments with a gallium aluminum arsenide infrared semiconductor continuous laser of 830 nanometer (nm) wavelength and 30 milliWatt output.  Laser was delivered at a power of 9 Joules per point at 5 points along the median nerve.  The primary outcome measure was disappearance of numbness and tingling for a minimum of 48 hours.  Secondary measures included neurological examination changes and improvement in distal latency.  The investigators reported that 77 % of cases achieved complete resolution of symptoms and abnormal physical findings.  They noted that nocturnal complaints were the earliest symptoms to disappear, followed by tingling, stiffness, and weakness.  The investigators considered 7 hands as treatment failures due to sensory nerve action potential or distal latency greater than 3.7 ms.  Limitation of this study included its small size, short duration, and lack of a control group.

Iwatsuki and colleagues (2007) performed laser denervation to the dorsal surface of the facet capsule, where it is richly innervated with medial nerve branches.  One year after laser denervation, 17 (81 %) of 21 patients experienced complete or greater than 70 % pain reduction.  Among the 6 patients who had previously undergone spinal surgery, 2 (33.3 %) experienced successful pain relief.  Overall, in 4 patients (19 %), the response to laser denervation at 1-year follow-ups was not successful.  The authors concluded that the dorsal surface of the facet capsule might be a more preferable target for facet denervation.  This was a small study with no control group; its findings need to be validated by well-designed studies.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
64600 - 64610
64620 - 64640
64702 - 64704
64708 - 64714
64727
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
354.0 Carpal tunnel syndrome
723.1 Cervicalgia
723.2 Cervicocranial syndrome
723.8 Other syndromes affecting cervical region
724.1 Pain in the thoracic spine
724.2 Lumbago
724.6 Disorders of sacrum [sacroiliac joint pain]
ICD-9 codes related to the CPB:
350.1 - 359.9 Disorders of peripheral nervous system


The above policy is based on the following references:
  1. Padua L, Padua R, Aprile I, et al. Noninvasive laser neurolysis in carpal tunnel syndrome. Muscle Nerve. 1998;21(9):1232-1233.
  2. Weintraub MI. Noninvasive laser neurolysis in carpal tunnel syndrome. Muscle Nerve. 1997;20(8):1029-1031.
  3. Hogan QH, Abram SE. Neural blockade for diagnosis and prognosis. Anesthesiology. 1997;86(1):216-241.
  4. Crook J, Tunks E. Pain clinics. Rheum Dis Clin North Am. 1996;22(3):599-611.
  5. Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med. 2007;39(3):225-229.
  6. Straube S, Derry S, Moore RA, McQuay HJ. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev. 2010;(7):CD002918.
  7. Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Encinitas, CA: Work Loss Data Institute; 2011.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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