Apos Therapy System

Policy ID: E-87-001

Section: Durable Medical Equipment

Effective Date: July 01, 2020

Last Reviewed: May 20, 2021

Description

The AposTherapy System consists of a pair of shoe-like uppers with two convex units (Pertupods) on the sole of each device, a screw fixation mechanism for securely attaching the Pertupod to the track and, if required, soft spacers, weight discs, hard spacers, and wedge spacers. Separately marketed and commercially available off-the-shelf (OTS) gait analysis software is used by practitioners to inform their calibration of the biomechanical device. Based on a preliminary evaluation of pain, function, and activities of daily life, a personalized therapy program is created to meet the individual’s treatment needs using the personally calibrated device to help relieve pressure and pain from symptomatic joint and improve control of the muscular system and function. This is achieved by challenging the individual in a barely perceptible manner through the creation of micro-instability.

Practitioners use basic, OTS gait analysis software to collect measurements from various movements (e.g., velocity, step length, single limb support) as part of the treatment program. The individual’s progress is assessed periodically; the device is then further adjusted, and the therapy program updated as needed to achieve the predefined goals.

Criteria

AposTherapy System may be considered medically necessary when ALL of the following criteria are met:

A diagnosis of moderate or advanced knee joint disease, supported by clinically appropriate (radiographic or MRI) imaging and clinical diagnosis of osteoarthritis; and
Documentation of persistent pain that is not controlled despite optimal, conservative pain management:
- To include a description of the pain (onset, character, aggravating, duration, and relief factors), analgesics and the treatment modalities used; and
Documentation of functional limitations that interfere with activities of daily living (ADLs):
- To include the specific limitation of ADLs; and
- To include an evaluation of safety issues (i.e. fall risk); and

Documentation of a history of conservative medical therapy that has been tried and failed including but not limited to ONE OR MORE of the following:
- Activity modification; or
- Structured land-based programs including strengthening and/or cardio and/or balance training/neuromuscular exercise; or
- Mind-body exercise including Tai Chi or Yoga; or
- Physical therapy that includes flexibility and muscle strengthening exercises; or
- NSAIDS; or
- Therapeutic intra-articular (knee) injections as appropriate; or
- Weight loss efforts as appropriate

Use of AposTherapy System not meeting the criteria above will be considered not medically necessary.

AposTherapy System is considered not medically necessary with the presence of following:

Active infection of the knee joint (i.e. active septic arthritis) or an active infectious process anywhere in the body (i.e. systemic bacteremia); or
Individual requires a cane or walker both indoors and outdoors; or
Individual has a history of two (2) or more unexplained falls within the last 12 months; or
Individual has severe neurological, psychiatric, or comprehension issues preventing an understanding of how to use the device; or
Individual has severe balance or vertigo issues

Procedure Codes

97799

Diagnosis Codes

Covered Diagnosis Codes

M17.0	M17.10	M17.11	M17.12	M17.2	M17.30	M17.31
M17.32	M17.4	M17.5	M17.9	M25.561	M25.562	M25.569
R26.9	R26.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 New policy

Internal Medical Policy Committee 5-20-2021 Annual Review-no change in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.