Currentharvard pilgrim health carePolicy N/A

AposTherapy foot‑worn biomechanical device — medical necessity guideline

Medical necessity guideline for use of the AposTherapy foot‑worn biomechanical device to treat adults with chronic knee osteoarthritis or chronic low back pain for Harvard Pilgrim Health Care commercial products.

Policy Summary

Payerharvard pilgrim health care

PolicyAposTherapy foot‑worn biomechanical device — medical necessity guideline

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionSubmit supporting clinical documentation including diagnosis, imaging (for knee), symptom duration, prior conservative treatments, and use CPT/HCPCS code 97799 for billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Conditions addressed

3m / 6mMinimum symptom duration

97799Billing code

NoPrior auth

CommercialApplies to

Coverage and Medical Necessity Criteria

Policy Summary

Payerharvard pilgrim health care

PolicyAposTherapy foot‑worn biomechanical device — medical necessity guideline

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionSubmit supporting clinical documentation including diagnosis, imaging (for knee), symptom duration, prior conservative treatments, and use CPT/HCPCS code 97799 for billing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Knee: Medical Necessity Criteria

Covered when ALL of the following are met:

Knee Criteria: 1) Clinical diagnosis of knee osteoarthritis confirmed by appropriate imaging that has persisted for at least 3 months; 2) Member meets criteria to qualify for knee surgery (including total knee replacement) but prefers a less invasive treatment option; 3) Member has persistent chronic knee pain that is impacting their quality of life, including limitations in activities of daily living; 4) Member has persistent pain that is not controlled despite conservative pain management, including but not limited to: (a) Therapeutic exercise program including strengthening, flexibility, and balance training; (b) Physical therapy/manual therapy; (c) Pharmaceutical treatment options (e.g., NSAIDs, topical steroids, intra-articular knee injections as appropriate); (d) Weight loss efforts as appropriate.duration >= 3 months

All subcriteria must be met

Low Back: Medical Necessity Criteria

Covered when ALL of the following are met:

Low Back Criteria: 1) Diagnosis of chronic low back pain that has persisted for more than 6 months; 2) Member meets referral criteria for back surgery but prefers a less invasive treatment option; 3) Chronic low back pain is impacting the member's quality of life, including limitations in activities of daily living; 4) Member has persistent pain that is not controlled despite conservative pain management, including but not limited to: (a) Therapeutic exercise program including strengthening, flexibility, and balance training; (b) Physical therapy/manual therapy; (c) Pharmaceutical treatment options (e.g., NSAIDs, opioids, topical steroids, intra-articular injections as appropriate); (d) Weight loss efforts as appropriate.duration > 6 months

All subcriteria must be met

The Plan does not consider AposTherapy Systems medically necessary for the treatment of any diagnosis other than knee osteoarthritis or chronic low back pain.

AposTherapy should not be used when the member has listed contraindications. Contraindications include: severe balance or vertigo issues, history of falls, peripheral neuropathy, severe osteoporosis, active infection of the affected joint, requires the use of an assistive walking device, or any other manufacturer-noted contraindication. Use in these situations may be considered not medically necessary.

Provider Requirements and Documentation

Prior Authorization

Prior Authorization Not Required

Prior authorization is not required for Harvard Pilgrim Health Care commercial products. Providers must verify plan-specific rules and contact Harvard Pilgrim for confirmation when appropriate.

Harvard Pilgrim Health Care Commercial products: prior authorization not required; provider line: 800-232-0816
Verify benefits and any plan-specific requirements before delivering services

Step Therapy

Conservative Therapy Required Prior to AposTherapy

Conservative therapy trials are required prior to AposTherapy for both knee and low back indications. Document attempts and durations of non‑surgical management.

Therapeutic exercise program (strengthening, flexibility, balance)
Physical therapy and/or manual therapy
Appropriate pharmaceutical treatment (e.g., NSAIDs, topical steroids, intra-articular knee injections; for low back may include opioids when appropriate)
Weight loss efforts as appropriate

Documentation Required

Required Clinical Documentation

Required clinical documentation must be submitted to support medical necessity for AposTherapy. Include objective findings and prior treatment records.

Diagnosis with supporting imaging (e.g., imaging confirming knee osteoarthritis or documentation of chronic low back pain)
Documentation that pain has persisted for the required time period (knee ≥ 3 months; low back > 6 months)
Evidence the member meets criteria for surgical referral but prefers less invasive options
Records of conservative management trials (therapy notes, exercise program, medications, injections, weight loss efforts) and response
Assessment of functional impact/limitations in activities of daily living
Calibration records and treatment plan from an AposTherapy Trained Clinician (ATC) if device provided

Denial Risk

Contraindications May Trigger Denial

Presence of contraindications may result in denial of AposTherapy requests. Assess and document absence of these conditions before approval.

Severe balance disorders or significant vertigo
History of falls
Peripheral neuropathy
Severe osteoporosis
Active infection of the affected joint
Requirement for an assistive walking device
Any other manufacturer-stated contraindication or clinical condition that would make AposTherapy unsafe

Background

The AposTherapy System is a foot-worn biomechanical device featuring adjustable convex perturbation units mounted on a shoe-like platform. These convex units are positioned under the hindfoot and forefoot and are calibrated by a trained clinician to customize location, weight, and convexity for the individual. The device is intended to redistribute load away from painful knee and low back areas and to retrain gait through a personalized treatment program that includes assessment, calibration, home use, and monitoring.

Definitions

Pertupods

TermPertupods

DescriptionConvex perturbation units mounted below the hindfoot and forefoot regions on the AposTherapy shoe-like platform

AdjustabilityPertupods and spacers are adjustable to customize location, weight, and convexity to meet individual member needs

FunctionRedistribute load away from painful knee and back areas to decrease pain and retrain gait

PlacementLocated below the main weight-bearing areas of the hindfoot and forefoot on each foot

AposTherapy Trained Clinician (ATC)

TermAposTherapy Trained Clinician (ATC)

RoleClinician or physical therapist specially trained to calibrate the AposTherapy device for each patient

Calibration TasksUtilizes clinical findings, computerized gait laboratory and questionnaire results, gait pattern, and AposTherapy methodology to calibrate location, weight, and convexity of each Pertupod

PersonalizationPerforms initial assessment and personalizes the device as part of the 4-step treatment plan (assessment, personalization, at-home treatment, monitoring)

GoalAdjust device to help retrain the patient to walk in a pain-free pattern even when not wearing the device

OpenPayer

AposTherapy foot‑worn biomechanical device — medical necessity guideline

Coverage and Medical Necessity Criteria

Billing and Diagnosis Codes

Provider Requirements and Documentation

Background

Definitions