CPT 97037 is referenced in 13 tracked payer policy changes from Sentara Health Plans, Medical Mutual of Ohio, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 97037 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Medical Mutual released a September 2026 policy newsletter with multiple medical policy updates including 5 new policies (low-frequency ultrasound therapy, phrenic nerve stimulation, gastric electrical stimulation, drug-eluting sinus devices, and sleep studies), 3 archived/retired policies, and updates to existing policies affecting billing codes. Key code changes include additions to prior authorization lists for EMDR (archived), low-level laser therapy (CPT 1011T, 97037), peripheral nerve stimulation (HCPCS A4541, E0733 reinstated), and skin surveillance (CPT 1020T). Multiple Avalon laboratory billing codes (G-codes and M-codes) were updated. Administrative changes are effective 15 days from September 1, 2026; material changes effective 90 days; new prior authorizations effective 30 days.
Multiple medical policies are being updated with changes to prior authorization requirements, covered diagnosis codes, and billing procedures across various specialties. Key changes include removal of prior authorization for several CPT codes, addition of new ICD-10 codes for breast cancer-related services, and updates to genetic testing coverage criteria.
Humana's Medicare Advantage Outpatient Rehabilitation (Skilled Therapy) policy HUM-1186-011 was revised with an effective date of 11/05/2026, and its Change Summary logs a "CMS document update required" entry on that date, along with a 10/01/2026 coverage change. The revision updates the related CMS LCD/LCA references and coding information for PT/OT and related modalities, including high power laser therapy (97039, 97139), which the policy states will not be considered reasonable and necessary. Billing teams should confirm current coverage for the listed codes against the revised policy text and the cited MAC LCDs for their jurisdiction.
Low-level laser therapy may be considered medically necessary when the device is FDA-approved and the request is for prevention of oral mucositis in individuals undergoing cancer treatment with increased risk of oral mucositis, including chemotherapy, radiotherapy, or hematopoietic cell transplantation. Low-level laser therapy is considered investigational when these criteria are not met. There is not enough research to show that low-level laser therapy, including laser acupuncture, improves health outcomes for conditions other than oral mucositis, including carpal tunnel syndrome, various musculoskeletal conditions, and wound healing.
Low-level laser therapy, also called photobiomodulation, may be considered medically necessary for prevention of oral mucositis in individuals undergoing cancer treatment associated with increased risk of oral mucositis, including chemotherapy, radiotherapy, or hematopoietic cell transplantation, when the device is FDA-approved. It is considered investigational when those criteria are not met. This version of the policy is effective October 1, 2026.
Independence Blue Cross Medicare Advantage has added CPT code 1011T (Photobiomodulation therapy of oral cavity) as a medically necessary code effective 01/01/2026 for low-level laser therapy used to prevent oral mucositis in cancer patients undergoing chemotherapy, radiotherapy, or stem cell transplantation. Billing teams must implement this new code in their systems and ensure proper documentation of eligible diagnoses to avoid claim denials.
Independence Blue Cross added CPT code 1011T (Photobiomodulation therapy of oral cavity) effective January 1, 2026, as a medically necessary procedure for prevention of oral mucositis in cancer patients undergoing chemotherapy, radiotherapy, or hematopoietic stem cell transplantation. All other LLLT applications remain experimental/investigational and non-covered. Billing teams must ensure claims use the correct code and include required ICD-10 diagnosis codes to avoid denials and audit exposure.
Aetna's clinical policy bulletin CPB 0363 addresses cold laser (low-level laser therapy, class III) and high-power laser (class IV) therapies. Aetna considers low-level laser therapy medically necessary for prevention of oral mucositis in persons undergoing cancer treatment with an increased risk of oral mucositis, including chemotherapy and/or radiotherapy, and/or hematopoietic stem cell transplantation. Aetna considers cold laser therapy, high-power laser therapy, and low-level laser therapy using dynamic photonic and dynamic thermokinetic energies experimental, investigational, or unproven for other indications, including Achilles tendinopathy, carpal tunnel syndrome, knee osteoarthritis, plantar fasciitis, rheumatoid arthritis, shoulder impingement syndrome, tinnitus, and tendon repair, because there is inadequate evidence of their effectiveness for those indications. CPT 97037 and HCPCS S8948 are listed as not covered for the indications in the policy.
Low-level laser therapy may be considered medically necessary for preventing oral mucositis in individuals undergoing cancer treatment with increased risk of oral mucositis, including chemotherapy, radiotherapy, or hematopoietic cell transplantation. It is considered investigational for all other indications, including carpal tunnel syndrome, low back pain, subacromial impingement, adhesive capsulitis, knee osteoarthritis, rheumatoid arthritis, wound healing, and lymphedema. The policy description was updated on 09/21/2026 regarding laser acupuncture, with minor changes to the policy statement.
Independence Blue Cross Medicare Advantage has reissued policy MA07.036d on Low-Level Laser Therapy, clarifying that LLLT is covered only for prevention of oral mucositis in cancer patients undergoing chemotherapy, radiotherapy, or stem cell transplantation. All other LLLT uses remain experimental/investigational and non-covered. CPT code 97037 was added to the experimental category as of 01/02/2024. Billing teams must ensure claims use only approved codes (1011T for covered oral mucositis cases) and avoid misrepresenting LLLT services with incorrect codes like 97026.
Independence Blue Cross reissued Policy 07.00.14h on 10/29/2025 to communicate its continuing position on Low-Level Laser Therapy (LLLT). The policy covers LLLT only for prevention of oral mucositis in cancer patients undergoing chemotherapy, radiotherapy, or stem cell transplant; all other uses remain experimental/investigational and non-covered. CPT code 97037 was added to the experimental/investigational category effective 01/02/2024, and billing teams must not misrepresent LLLT services using incorrect codes like 97026.
This is a reissue with no substantive changes to Independence Blue Cross Commercial Policy 10.03.01o on Outpatient Physical Medicine, Rehabilitation, and Habilitation Services. The policy was last reviewed and reissued on 09/18/2026 per the company's annual review process. Key coverage requirements, modifier mandates (GO for OT, GP for PT), experimental/investigational exclusions (including LLLT and CPT 97037), and state mandate considerations for Autism Spectrum Disorders remain unchanged.
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