Laser Neurolysis

Number: 0552

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses laser neurolysis.

1. Experimental and Investigational

   Aetna considers laser peripheral nerve block (laser neurolysis) experimental and investigational for the following indications (not an all-inclusive list) because of insufficient evidence regarding its effectiveness:

   1. Carpal tunnel syndrome
   2. Complex regional pain syndrome
   3. Facet joint pain
   4. Phantom limb pain
   5. Sacroiliac joint pain.

2.  Related Policies

   • CPB 0363 - Cold Laser and High-Power Laser Therapies.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
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):
G54.6	Phantom limb syndrome with pain
G56.00 - G56.03	Carpal tunnel syndrome
G56.40 - G56.42	Causalgia of upper limb [Complex regional pain syndrome II of upper limb]
G57.70 - G57.73	Causalgia of lower limb [Complex regional pain syndrome II of lower limb]
G90.50 - G90.59	Complex regional pain syndrome I (CRPS I) [Complex regional pain syndrome I of upper and lower limb]
M53.0	Cervicocranial syndrome
M53.3	Sacrococcygeal disorders, not elsewhere classified [sacroiliac joint pain]
M53.82 - M53.83	Other specified dorsopathies cervical and cervicothoracic region
M54.2	Cervicalgia
M54.50 - M54.59	Low back pain
M54.6	Pain in the thoracic spine

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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.

Complex Regional Pain Syndrome

In a Cochrane review, Smart and colleagues (2016) determined the effectiveness of physiotherapy interventions for treating the pain and disability associated with complex regional pain syndrome (CRPS) types I and II. These investigators searched the following databases from inception up to February 12, 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments, without language restrictions, for randomized controlled trials (RCTs) of physiotherapy interventions for treating pain and disability in people CRPS.  They also searched additional online sources for unpublished trials and trials in progress.  These researchers included RCTs of physiotherapy interventions (including manual therapy, therapeutic exercise, electrotherapy, physiotherapist-administered education and cortically directed sensory-motor rehabilitation strategies) employed in either a stand-alone fashion or in combination, compared with placebo, no treatment, another intervention or usual care, or of varying physiotherapy interventions compared with each other in adults with CRPS I and II.  The primary outcomes of interest were patient-centered outcomes of pain intensity and functional disability.  Two review authors independently evaluated those studies identified through the electronic searches for eligibility and subsequently extracted all relevant data from the included RCTs.  Two review authors independently performed "risk of bias" assessments and rated the quality of the body of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.  The authors included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions.  Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I.  Most included trials were at "high" risk of bias (15 trials) and the remainder were at "unclear" risk of bias (3 trials).  The quality of the evidence was very low or low for all comparisons, according to the GRADE approach.  These investigators found very low quality evidence that graded motor imagery (GMI; 2 trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) -21.00, 95 % confidence interval [CI]: -31.17 to -10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95 % CI: 1.12 to 3.48), at long-term (6 months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multi-modal physiotherapy (1 trial, 135 participants) may be useful for improving "impairment" at long-term (12 months) follow-up compared to a minimal "social work" intervention; and very low quality evidence that mirror therapy (2 trials, 72 participants) provided clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95 % CI: -4.71 to -2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD -2.3, 95 % CI: -2.88 to -1.72) at long-term (6 months) follow-up in people with CRPS I post stroke compared to placebo (covered mirror).  There was low-to-very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-term in people with CRPS I.  They noted that laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I.  Adverse events were only rarely reported in the included trials; no trials including participants with CRPS II met the inclusion criteria of this review.  The authors concluded that the best available data showed that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low.  Evidence of the effectiveness of multi-modal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear.  They stated that large scale, high quality RCTs are needed to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II.

Phantom Limb Pain

Ghoseiri and colleagues (2018) stated that the prevalence of limb amputation is increasing globally as a devastating experience that can physically and psychologically affect the lifestyle of a person.  The residual limb pain and phantom limb pain are common disabling sequelae after amputation surgery.  Assistive devices/technologies can be used to relieve pain in people with amputation.  The existing assistive devices/technologies for pain management in people with amputation include electrical nerve block devices/technologies, TENS units, elastomeric pumps and catheters, residual limb covers, laser systems, myoelectric prostheses and virtual reality systems, etc.  There is a great potential to design, fabricate, and manufacture some portable, wireless, smart, and thin devices/technologies to stimulate the spinal cord or peripheral nerves by electrical, thermal, mechanical, and pharmaceutical stimulus.  The authors concluded that although some preliminary efforts have been done, more attention must be paid by researchers, clinicians, designers, engineers, and manufacturers to the post-amputation pain and its treatment methods.

Furthermore, an UpToDate review on "Lower extremity amputation" (Kalapatapu, 2018) does not mention laser neurolysis/laser peripheral nerve block as a management tool.

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References