Apos Therapy System

Policy ID: E-87-005

Section: Durable Medical Equipment

Effective Date: July 01, 2020

Revised Date: December 13, 2024

Revision Effective Date: September 01, 2025

Last Reviewed: June 10, 2025

Applies To: Commercial and Medicaid Expansion

Description

AposTherapy uses a biomechanical shoe device that helps to reduce pain by retraining muscles in the knees, hips, and back. Physical therapists conduct evaluations to initiate therapy and calibrate the device to reduce pressure on painful joints.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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

A diagnosis of ONE or MORE of the following:
- A diagnosis of moderate or advanced knee joint disease, supported by clinically appropriate (radiographic or MRI) imaging and clinical diagnosis of osteoarthritis; or
- A diagnosis of moderate or advanced low back pain, lasting six (6) months or more, with the presence of ONE OR MORE of the following:
  - Reports of morning spinal stiffness; or
  - Reports of physical limitations due to back pain; or
  - Imaging with disc space narrowing, disc degeneration and/or osteophytes; 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 peripheral neuropathy; or
Individual has severe osteoporosis; or
Individual has severe balance or vertigo issues

Procedure Code

97799

Diagnosis Codes

Not Applicable

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

Internal Medical Policy Committee 9-28-2022 Annual Review - no change in criteria

Internal Medical Policy Committee 11-29-2022 Policy Reviewed

Internal Medical Policy Committee 1-26-2023 Coding update

Removed Diagnosis Codes M17.0; M17.10; M17.11; M17.12; M17.2; M17.32; M17.4; M 17.5; M17.9; M25.561; R26.9; and R26.89.

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Addition of back pain as medically necessary; and
Addition of peripheral neuropathy and severe osteoporosis as NOT medically necessary

Internal Medical Policy Committee 1-14-2025 Annual Review - no changes in criteria

Added Policy Application

Internal Medical Policy Committee 6-10-2025 Annual Review - no changes 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.

Policy ID: E-87-004

Section: Durable Medical Equipment

Effective Date: July 01, 2020

Revised Date: December 13, 2022

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Archived Date: August 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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

A diagnosis of ONE or MORE of the following:
- A diagnosis of moderate or advanced knee joint disease, supported by clinically appropriate (radiographic or MRI) imaging and clinical diagnosis of osteoarthritis; or
- A diagnosis of moderate or advanced low back pain, lasting six (6) months or more, with the presence of ONE OR MORE of the following:
  - Reports of morning spinal stiffness; or
  - Reports of physical limitations due to back pain; or
  - Imaging with disc space narrowing, disc degeneration and/or osteophytes; 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 peripheral neuropathy; or
Individual has severe osteoporosis; or
Individual has severe balance or vertigo issues

Procedure Code

97799

Diagnosis Codes

Not Applicable

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

Internal Medical Policy Committee 9-28-2022 Annual Review - no change in criteria

Internal Medical Policy Committee 11-29-2022 Policy Reviewed

Internal Medical Policy Committee 1-26-2023 Coding update

Removed diagnosis codes M17.0; M17.10; M17.11; M17.12; M17.2; M17.32; M17.4; M 17.5; M17.9; M25.561; R26.9; and R26.89.

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Addition of back pain as medically necessary; and
Addition of peripheral neuropathy and severe osteoporosis as NOT medically necessary

Internal Medical Policy Committee 1-14-2025 Annual Review - no changes in criteria

Added Policy Application

Medical Policies Quick Search

Apos Therapy System

Description

Policy Application

Criteria

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer