Red Light Therapy (RLT) is a non-invasive treatment that uses low-level, specific wavelengths of light, typically in the red and near-infrared spectrums, to stimulate cellular function. For Medicare beneficiaries, coverage for RLT is highly conditional. Coverage depends less on potential benefits and more on established medical necessity and regulatory approval, requiring the treatment to be classified as a standard, proven medical service rather than an experimental technique.
The General Coverage Rule for Red Light Therapy
Original Medicare (Part A and Part B) only covers services and items deemed “reasonable and necessary” for the diagnosis or treatment of an illness or injury. RLT often encounters two major hurdles: classification as experimental and lack of a specific coverage policy. The Centers for Medicare & Medicaid Services (CMS) has not issued a National Coverage Determination (NCD) that broadly approves RLT devices or services.
A specific NCD exists for Infrared Therapy Devices, which utilize near-infrared wavelengths associated with RLT. This policy explicitly states that coverage is not provided for infrared or near-infrared light used to treat conditions like diabetic peripheral neuropathy or chronic wounds. This determination effectively classifies many forms of RLT as non-covered investigational treatments under Original Medicare Part B.
Without a favorable national policy, coverage defaults to local decision-making by Medicare Administrative Contractors (MACs) through Local Coverage Determinations (LCDs). MACs establish coverage guidelines for their specific geographic areas. These LCDs must still adhere to the “reasonable and necessary” standard and are cautious about covering therapies that lack extensive clinical evidence.
The provider must demonstrate that the specific RLT service is medically necessary and an established, effective treatment protocol. Since most RLT applications are not recognized as standard care, beneficiaries generally expect to pay for these services out-of-pocket. This includes in-office treatments and home-use devices, which typically do not qualify as Durable Medical Equipment (DME).
Specific Medical Applications That May Qualify
While RLT is largely excluded, Medicare covers specific forms of phototherapy for a narrow range of dermatological conditions. For example, ultraviolet (UV) phototherapy is a covered service for certain skin conditions when administered in a physician’s office or clinic setting. This includes treatment for moderate-to-severe psoriasis, vitiligo, and certain forms of dermatitis.
These covered phototherapies use different light wavelengths than RLT. They are administered using devices that have received specific Food and Drug Administration (FDA) approval for treating these diseases. Coverage requires the treatment to be overseen by an authorized provider, often a dermatologist, and properly billed using specific Healthcare Common Procedure Coding System (HCPCS) codes. The treatment must also follow established protocols and demonstrate a measurable medical benefit.
The distinction is important because RLT uses red and near-infrared light for applications like tissue repair and pain relief, uses that are generally excluded. For chronic, non-healing wounds, Medicare’s current policy prevents coverage for the light device itself, even if low-level light therapy is used adjunctively. A beneficiary must confirm that the specific light-based treatment falls under a recognized, covered phototherapy category, not the generally excluded RLT/infrared category.
Coverage Through Medicare Advantage Plans
Medicare Advantage plans (Part C) are offered by private insurance companies approved by CMS as an alternative to Original Medicare. While these plans must cover all Original Medicare services, they often provide additional benefits that offer broader coverage options. This structure introduces the possibility for RLT coverage as a supplemental benefit.
Supplemental benefits are extra services not covered by Original Medicare but included by the private plan to enhance health coverage. A Medicare Advantage plan may choose to cover RLT, or similar photobiomodulation therapies, under a specific wellness or supplemental category. This might include a limited number of sessions or a discount toward a home-use device.
Coverage availability is highly variable and depends entirely on the specific plan chosen. Before receiving RLT, individuals must consult their Evidence of Coverage (EOC) document. Prior authorization is almost always required for supplemental benefits, and the service may only be covered if performed by a provider within the plan’s specific network.
Steps for Verifying Coverage and Appealing Denials
Before undergoing Red Light Therapy, the first step is to contact the provider’s billing office and request formal verification of coverage. The provider should check the specific HCPCS code against the patient’s plan. Beneficiaries should insist on receiving a written statement or a pre-determination of benefits to confirm coverage and expected out-of-pocket costs.
If coverage is denied, or a claim is rejected, the beneficiary has the right to appeal the decision. The appeal process for Original Medicare begins with a Redetermination, a formal review of the claim by the Medicare Administrative Contractor (MAC). This request must typically be filed within 120 days of receiving the Medicare Summary Notice (MSN) that indicates the denial.
If the Redetermination is unsuccessful, the appeal can proceed through four additional levels, including a Reconsideration by a Qualified Independent Contractor (QIC) and a hearing before an Administrative Law Judge (ALJ). Throughout this process, gather supporting documentation from the treating physician, such as medical records and a letter explaining the medical necessity of the RLT. For Medicare Advantage plans, the initial appeal steps and deadlines follow the specific procedures outlined in the plan’s denial notice.