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    v1.0.28
    OpenPayerPolicy UpdatesOrthopedics/MusculoskeletalHarvard Pilgrim AposTherapy Coverage Update | Open…
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    Currentharvard pilgrim health carePolicy N/A

    AposTherapy foot‑worn biomechanical device — medical necessity guideline

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    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
    Last ReviewJan 21, 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

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    97799Billing code
    NoPrior auth
    CommercialApplies to

    Coverage and Medical Necessity Criteria

    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.

    Billing and Diagnosis Codes

    CPT/HCPCS CodesCPT
    97799Unlisted Rehabilitation Service or Procedure
    Associated ICD-10 CodesICD-10
    ICD-10 list (external link)List of ICD-10 codes for which AposTherapy may be medically necessary (see linked PDF)

    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)

    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)
    Term
    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
    Last ReviewJan 21, 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
    Coverage and Medical Necessity CriteriaBilling and Diagnosis CodesProvider Requirements and DocumentationBackgroundDefinitions
  1. Weight loss efforts as appropriate
    2. 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
    AposTherapy 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