Currentpriority healthPolicy N/A

Digital Therapeutics

Defines Priority Health coverage stance for digital therapeutics (DTx), including which products are considered medically necessary and which are experimental/not covered; applies to Priority Health members and providers subject to member-specific benefits.

Policy Summary

Payerpriority health

PolicyDigital Therapeutics

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain and document a clinician prescription and supporting indication when requesting coverage for the d-Nav® System.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1DTx listed as medically necessary

All othersOther DTx treated as not medically necessary

MultipleCPT/HCPCS codes listed

12+References cited

Coverage Criteria for Digital Therapeutics

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.

Exclusions / Not Medically Necessary

Not covered (considered not medically necessary / experimental)

Exclusions: All other digital therapeutics (DTx), including the DTx software and any associated ancillary components, that are not expressly listed as inclusions are considered not medically necessary for any indication or use and are experimental, investigational, or unproven due to insufficient evidence.

Includes, but is not limited to: 1) Non-prescription digital therapeutics (OTC); 2) Prescription digital therapeutics prescribed for direct-to-consumer or stand-alone use without healthcare provider guidance; 3) DTx used in conjunction with or to enhance another device or treatment.

Coding — CPT, HCPCS, DME and Related Codes

Covered CPT Codes (selected list)CPT

0687T	Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session
0688T	Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified healthcare professional, with report, per calendar month
0704T	Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment
0705T	Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days
0706T	Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified healthcare professional, per calendar month
0731T	Augmentative AI-based facial phenotype analysis with report
0740T	Remote autonomous algorithm-based recommendation system for insulin dose calculation and titration; initial set-up and patient education
0741T	Remote autonomous algorithm-based recommendation system for insulin dose calculation and titration; provision of software, data collection, transmission, and storage, each 30 days
0770T	Virtual reality technology to assist therapy (List separately in addition to code for primary procedure)
0771T	Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

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Covered HCPCS/CPT and DME codes (selected list)mixed

0773T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older
0774T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
99199	Unlisted special service, procedure or report (when specified as a mobile-based health management software application., (Explanatory notes must accompany claim)
A9291	Prescription digital cognitive and/or behavioral therapy, FDA-cleared, per course of treatment
A9292	Prescription digital visual therapy, software-only, FDA cleared, per course of treatment
A9293	Fertility cycle (contraception & conception) tracking software application, FDA cleared, per month, includes accessories (e.g., thermometer)
A9999	Miscellaneous DME supply or accessory, not otherwise specified (when specified as a mobile-based health management software application (Explanatory notes must accompany claim)
E1399	Durable medical equipment, miscellaneous (when specified as a mobile-based health management software application. (Explanatory notes must accompany claim)
E1905	Virtual reality cognitive behavioral therapy device (CBT), including preprogrammed therapy software
G0552	Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan

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Covered CPT Codes (select DTx and VR-related codes)CPTCovered

0687T	Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session
0688T	Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified healthcare professional, with report, per calendar month
0704T	Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment
0705T	Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days
0706T	Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified healthcare professional, per calendar month
0731T	Augmentative AI-based facial phenotype analysis with report
0740T	Remote autonomous algorithm-based recommendation system for insulin dose calculation and titration; initial set-up and patient education
0741T	Remote autonomous algorithm-based recommendation system for insulin dose calculation and titration; provision of software, data collection, transmission, and storage, each 30 days
0770T	Virtual reality technology to assist therapy (List separately in addition to code for primary procedure)
0771T	Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

1–10 of 11

1/2

Covered HCPCS / DME / A-codes / miscellaneous entriesHCPCS | CPT | DMECovered

0773T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older
0774T	Virtual reality (VR) procedural dissociation services provided by a physician or other qualified healthcare professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
99199	Unlisted special service, procedure or report (when specified as a mobile-based health management software application., (Explanatory notes must accompany claim)
A9291	Prescription digital cognitive and/or behavioral therapy, FDA-cleared, per course of treatment
A9292	Prescription digital visual therapy, software-only, FDA cleared, per course of treatment
A9293	Fertility cycle (contraception & conception) tracking software application, FDA cleared, per month, includes accessories (e.g., thermometer)
A9999	Miscellaneous DME supply or accessory, not otherwise specified (when specified as a mobile-based health management software application (Explanatory notes must accompany claim)
E1399	Durable medical equipment, miscellaneous (when specified as a mobile-based health management software application. (Explanatory notes must accompany claim)
E1905	Virtual reality cognitive behavioral therapy device (CBT), including preprogrammed therapy software
G0552	Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan

1–10 of 11

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inv-13: Hemoglobin A1c — study baselines and reported mean reductions

Study populations / baselinesd-Nav RCT enrolled adults 21-70 with type 2 diabetes and baseline HbA1c 7.5%–11%.

Randomized trial mean baseline A1c (intervention vs control)Intervention 8.7% (SD 0.8); control 8.5% (SD 0.8).

Mean A1c reduction at 6 months (RCT)Intervention group mean decrease 1.0% (SD 1.0); control group 0.3% (SD 0.9).

Cohort study reported outcomesSingle-center cohort (first 600 patients) reduced mean HbA1c from ~8.6% ± 2.1% to 7.3% ± 1.2% with 82% retention over 8.2 ± 3.0 months.

inv-14: VR procedural dissociation time increments — initial 15 minutes; each additional 15 minutes

Initial VR procedural dissociation time incrementInitial 15 minutes of intraservice time is reported for codes 0771T/0773T.

Subsequent time incrementsEach additional 15 minutes of intraservice time billed with codes 0772T/0774T.

Applicability noteCodes are listed to be reported separately in addition to the primary procedure when VR dissociation supports another service.

inv-15: 0705T training hours minimum — minimum of 18 training hours, each 30 days

Minimum training hours for 0705TSurveillance center technical support for 0705T includes a minimum of 18 training hours, each 30 days.

Billing periodRequirement specified per each 30-day period associated with the service code.

Service contextApplies to remote treatment of amblyopia using an eye tracking device (0705T) for surveillance center technical support including data transmission and analysis.

Provider Actions, Authorization, and Documentation

Documentation Required

Prescription Required for PDTs

Use of prescription digital therapeutics (PDTs) requires a valid clinician prescription or authorization. d-Nav® (Hygieia) is prescription-only and must be prescribed by a licensed provider; documentation of the clinical indication, prescription details, and any accompanying orders must be retained in the medical record.

d-Nav® System (K181916) requires a prescription.
Document indication, prescribing clinician, date of prescription, duration, and any device-specific instructions.

Denial Risk

Denial Risk for Non‑Included DTx

Digital therapeutics not expressly listed as medically necessary inclusions in this policy are considered not medically necessary and are treated as experimental, investigational, or unproven. Claims for such non-included DTx are subject to denial unless an exception is approved via individual case review.

Non-included DTx (prescription or non-prescription) = Not medically necessary / Experimental.
Providers may request individual case review per policy for possible exception (e.g., terminal illness or severely disabling disease).

Documentation Required

Prescription and Regulatory Documentation

Regulatory and labeling information should be available to support coverage and documentation. Include FDA clearance/authorization details (e.g., d-Nav® System Premarket/510(k) K181916 and notice date 02/04/2019) with the clinical record when applicable.

Reference FDA listing: d-Nav® System K181916; include device identification in documentation.
Maintain copies or references to regulatory/labeling information when submitting prior authorization or claims.

Step Therapy

Step Therapy Not Addressed

This policy section does not establish or require a step therapy process for digital therapeutics. Step therapy requirements, if any, would be specified elsewhere in member benefit plans or prior authorization criteria.

Step therapy not addressed in this policy — follow member-specific benefits or prior authorization rules if applicable.

Prior Authorization

Prior Authorization and Individual Case Review

Prior authorization may be required for certain digital therapeutics, devices, or services. Submit prior authorization requests per Priority Health Provider Manual with complete clinical documentation demonstrating medical necessity. Individual case review may allow coverage for investigational yet promising treatments with prior plan approval.

Follow Priority Health Provider Manual for prior authorization submission requirements.
All experimental/investigational determinations are made by a Priority Health medical director or clinical pharmacist; exceptions considered for terminal or severely disabling conditions.

Billing Rule

Claims Documentation and Explanatory Notes

When billing for mobile-based health management applications or software-defined devices, include explanatory notes and any required supporting documentation on claims to clarify the product and clinical justification.

Use explanatory notes with codes such as 99199, A9999, E1399 when specified as mobile-based health applications.
Include prescription and clinical rationale when submitting claims for PDTs (e.g., A9291–A9293 where applicable).

Definitions

inv-25: Digital Therapeutics (DTx) — definition per policy

Core definitionDigital therapeutics (DTx) are health software intended to treat or alleviate a disease, disorder, condition, or injury by generating and delivering a medical intervention with a demonstrable positive therapeutic impact.

System componentsDTx can integrate with general-purpose hardware, wearables/sensors, pharmaceuticals, or clinician/patient support components to form a DTx system.

Distinction from wellness productsProducts that do not claim to treat or alleviate a disease (wellness products) do not qualify as DTx under the DTA/ISO definition.

inv-26: Prescription Digital Therapeutics (PDTs) — definition and access restrictions

Definition of PDTsPrescription Digital Therapeutics (PDTs) are DTx that require clinician initiation and oversight and are available only via prescription.

Regulatory implicationsPDTs undergo additional and more rigorous regulatory scrutiny; FDA may impose special controls, labeling, and pre/postmarket requirements.

Access restriction exampled-Nav is specified in the policy as a prescription-only DTx requiring clinician prescription and authorization documentation.

inv-27: Digital Therapeutic (DTx) — reference to Digital Therapeutics Alliance and ISO/TR materials

Source referencesPolicy references the Digital Therapeutics Alliance (DTA) adoption of the ISO definition and ISO/TR 11147:2023 for DTx terminology.

ISO standard citedISO/TR 11147:2023 — Health informatics — Personalized digital health — Digital therapeutics health software systems is cited as the ISO guidance adopted by DTA.

Interpretation by DTAThe Digital Therapeutics Alliance adopted the ISO definition; policy uses DTA wording to define DTx inclusion criteria.

OpenPayer

Digital Therapeutics

Coverage Criteria for Digital Therapeutics

Coding — CPT, HCPCS, DME and Related Codes

Provider Actions, Authorization, and Documentation

Background on Digital Therapeutics

Definitions