Number: Policy *Please see amendment for Pennsylvania Medicaid at the end. Last Review 06/09/2016 Effective: 08/14/2001 Next Review: 06/08/2017

Transcription

1 1 of 6 Number: 0552 Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB. Aetna considers laser peripheral nerve block (laser neurolysis) experimental and investigational for any indications (e.g., carpal tunnel syndrome, complex regional pain syndrome, facet or sacroiliac joint pain) because of insufficient evidence regarding its effectiveness. Last Review 06/09/2016 Effective: 08/14/2001 Next Review: 06/08/2017 Review History Definitions See also CPB 0363 Cold Laser and High Power Laser Therapies (../300_399/0363.html). Background Laser neurolysis is the non invasive application of laser to peripheral nerves. As such, it is a form of low level laser therapy. Clinical Policy Bulletin Notes 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

2 2 of 6 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,

3 3 of 6 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, physiotherapistadministered 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]: 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

4 4 of 6 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 Te st) (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. 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:

5 5 of 6 Other CPT codes related to the CPB: Destruction by neurolytic agent, trigeminal nerve Destruction by neurolytic agent, intercostal nerve, paravertebral facet joint nerve, or pudendal nerve Neuroplasty, digital, one or both, same digit or nerve of hand or foot Neuroplasty, major peripheral nerve, arm or leg, open 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 M53.0 Cervicocranial syndrome M53.3 Sacrococcygeal disorders, not elsewhere classified [sacroiliac joint pain] M53.82 Other specified dorsopathies cervical and M53.83 cervicothoracic region M54.2 Cervicalgia M54.5 Low back pain M54.6 Pain in the thoracic spine 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): Weintraub MI. Noninvasive laser neurolysis in carpal tunnel syndrome. Muscle Nerve. 1997;20(8): Hogan QH, Abram SE. Neural blockade for diagnosis and prognosis. Anesthesiology. 1997;86(1):

6 6 of 6 4. Crook J, Tunks E. Pain clinics. Rheum Dis Clin North Am. 1996;22(3): Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med. 2007;39(3): Straube S, Derry S, Moore RA, McQuay HJ. Cervicothoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev. 2010;(7):CD Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Encinitas, CA: Work Loss Data Institute; Smart KM, Wand BM, O'Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2016;2:CD 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. Copyright Aetna Inc.

7 AETNA BETTER HEALTH OF PENNSYLVANIA Amendment to Aetna Clinical Policy Bulletin Number: 0552 Laser Neurolysis There are no amendments for Medicaid. Updated 01/2017