Blue Cross and Blue Shield (Kansas) LLLT coding update

Blue Cross and Blue Shield Kansas (BCBS) have updated their assessment of LLLT and it is still considered “experimental” despite referencing the “strong evidence” conclusions in systematic reviews published by the British Medical Journal (BMJ) and International Society for the Study of Pain (IASP). Then there is The Lancet Systematic Review on Neck pain and the MASCC “recommendation” statements, also brushed aside by BCBS.

How can this be when:

The BMJ sports medicine journal, systematic review of surgical and conservative interventions for frozen shoulder found “strong evidence” for LLLT. (2010) Click here

The International Association for the Study of Pain (Global Task force on musculoskeletal pain) found “strong evidence” for Low Level Laser Therapy on myofascial pain syndrome. (2010) Click here

The Multinational Association for Supportive Care in Cancer (MASCC) are now “recommending” LLLT for for the prevention of Oral Mucositis during bone-marrow transplantation or stem cell transplant (HSCT) Click here

The systematic review published in the Lancet which found 16 RCTs, 820 patients (total) showed that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain by 22·07 mm (17·42–26·72). And this is for a pathology for which no drug is licensed. Click here

The main reasons for dismissing LLLT in the BCBS review are “small trials” and “inconsistent results”.

1) Small trials are not a bad thing because:

a) Big trials are usually industry financed (and consequently biased)

b) Effect sizes for LLLT are so large that fewer patients are required to reach statistical significance (when compared with drug trials).

2) There is a dose response which was ignored by the BCBS reviewers. LLLT research has tended to work in the reverse fashion to pharma. Pharma typically work on a new molecule to affect an enzyme that might have a physiological effect and maybe impact a disease symptom. With LLLT, doctors and therapists discover a new application, run a clinical trial, then someone research the mechanistic pathway afterwards. This approach has lead to many hit and miss clinical trials, but this is how the effective dose ranges have been found. When all trials are considered as a whole then, yes, the results are hit and miss, but when trials with irradiation parameters outside the WALT guidelines are excluded from systematic reviews then the effect size is consistently high.

In my conversation with Prof. Jan Bjordal yesterday about the BCBS statement, he summarised the issue succinctly like this: “this is how they want it”.

Well silly me, I am a fool for ranting because, yes, “this is how they want it”. Is the truth irrelevant?

You can download the BCBS PDF and read it for yourself. It is 19 pages long.

Click here to download PDF

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