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.
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-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|Other CPT codes related to the CPB:|
|64600 - 64610||Destruction by neurolytic agent, trigeminal nerve|
|64620 - 64640||Destruction by neurolytic agent, intercostal nerve, paravertebral facet joint nerve, or pudendal nerve|
|64702 - 64704||Neuroplasty, digital, one or both, same digit or nerve of hand or foot|
|64708 - 64714||Neuroplasty, major peripheral nerve, arm or leg, open|
|64727||Internal neurolysis, requiring the use of operating microscope (List separately in addition to code for neuroplasty|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|G56.00 - G56.02||Carpal tunnel syndrome|
|M53.3||Sacrococcygeal disorders, not elsewhere classified [sacroiliac joint pain]|
|M53.82 - M53.83||Other specified dorsopathies cervical and cervicothoracic region|
|M54.5||Low back pain|
|M54.6||Pain in the thoracic spine|