HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
E-87-003
Topic:
AposTherapy System
Section:
Durable Medical Equipment
Effective Date:
January 9, 2023
Issued Date:
January 9, 2023
Last Revision Date:
November 2022
Annual Review:
November 2022
 
 

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 patient’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 patient 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 patient’s progress is assessed periodically; the device is then further adjusted, and the therapy program updated as needed to achieve the pre-defined goals.  

Policy Position

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.

97799

 

 

 

 

 

 








Place of Service: Outpatient

AposTherapy System is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting. 



The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.