ModifiedColorado Rocky Mountain Health PlansPolicy MMP068.10

Orthopedic Procedures, Devices, and Products – Medicare Advantage Medical Policy

Medicare Advantage medical policy governing coverage guidance, applicable codes, and references to CMS LCDs/LCAs for computer-assisted surgical navigation for musculoskeletal procedures, extracorporeal shock wave therapy (ESWT), and manipulation under anesthesia (MUA) for the spine and pelvis; indicates reliance on applicable LCDs/LCAs and UnitedHealthcare commercial policies where LCDs/LCAs are absent.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOrthopedic Procedures, Devices, and Products – Medicare Advantage Medical Policy

Policy CodePolicy MMP068.10

Change TypeCoverage criteria and codes updated

Effective DateMay 1, 2026

Next Review Date

Key ActionWhen an LCD or LCA exists for the service, providers must follow and retain documentation demonstrating compliance with that LCD/LCA when requested

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale for Computer-Assisted Surgical Navigation for Musculoskeletal Procedures was updated

Applicable Codes section edited

Centers for Medicare and Medicaid Services (CMS) Related Documents updated

Archived previous policy version MMP068.09

3Procedural topics referenced (Navigation, ESWT, MUA)

8Codes listed

Coverage Summary

This Medicare Advantage coverage policy provides guidance for orthopedic procedures, devices, and products (Policy No. MMP068.10) and is intended to align UnitedHealthcare coverage decisions with applicable Centers for Medicare & Medicaid Services (CMS) National and Local Coverage Determinations. The policy relies on applicable LCDs/LCAs where they exist, and cross-references UnitedHealthcare commercial medical policies when Medicare guidance is absent or flexible. Effective date: May 1, 2026. Last review / committee approval date: April 8, 2026.

Policy metadata

policy_numberMMP068.10

subjectOrthopedic Procedures, Devices, and Products

scope_summaryMedicare Advantage medical policy governing coverage guidance, applicable codes, and references to CMS LCDs/LCAs for computer-assisted surgical navigation for musculoskeletal procedures, extracorporeal shock wave therapy (ESWT), and manipulation under anesthesia (MUA) for the spine and pelvis; indicates reliance on applicable LCDs/LCAs and UnitedHealthcare commercial policies where LCDs/LCAs are absent.

effective_date2026-05-01

last_review2026-04-08

statusMODIFIED

Medical-Necessity Criteria by Topic

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures

Coverage follows applicable LCDs/LCAs; where no LCD/LCA exists, refer to UnitedHealthcare Commercial Medical Policy

ALL of the following

If an applicable Local Coverage Determination (LCD) or Local Coverage Article (LCA) exists, compliance with that LCD/LCA is required
If no LCD/LCA exists for a state/territory, refer to the UnitedHealthcare Commercial Medical Policy titled 'Computer-Assisted Surgical Navigation for Musculoskeletal Procedures' for coverage guidelines
For specific LCDs/LCAs, refer to the CMS Related Documents table in the policy

Extracorporeal Shock Wave Therapy (ESWT)

Coverage follows applicable LCDs/LCAs; where none exist, refer to UnitedHealthcare Commercial Medical Policy

Applicable Codes

Computer-Assisted Surgical Navigation - referenced CPT/HCPCSmixed

0054T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
27599	Unlisted procedure, femur or knee (e.g., kinetic balance sensor)

Extracorporeal Shock Wave Therapy (ESWT) - referenced CPT/HCPCSmixed

0101T	Extracorporeal shock wave involving musculoskeletal system, not otherwise specified
0102T	Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia

Manipulation Under Anesthesia (MUA) for the Spine and Pelvis - referenced CPTCPT

22505

Manipulation of spine requiring anesthesia, any region

Provider Actions and Documentation Requirements

Documentation Required

Comply with applicable LCDs/LCAs

When an applicable Local Coverage Determination (LCD) or Local Coverage Article (LCA) exists for the service, providers must follow that LCD/LCA and retain documentation demonstrating compliance. Keep supporting records and make them available if requested for audit or review.

retain supporting records for audit

Documentation Required

Refer to UnitedHealthcare commercial policies when no LCD/LCA

For states or territories without an applicable LCD or LCA, follow the referenced UnitedHealthcare Commercial Medical Policy for the service and retain supporting documentation showing how the decision was made. No specific codes are required by this instruction; maintain records that can be produced if requested.

Medicare LCDs/LCAs Referenced

Type (LCD/LCA)	Number	Name	Effective Date
LCD	L40232	Total Joint Arthroplasty	2026-03-15
LCA	A60250	Billing and Coding: Total Joint Arthroplasty	2026-03-15
LCD	L38775	Extracorporeal Shock Wave Therapy (ESWT)
LCA	A58367	Billing and Coding: Extracorporeal Shock Wave Therapy (ESWT)

Background and Definitions

This policy aligns UnitedHealthcare Medicare Advantage coverage decisions with applicable CMS Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs); when an LCD/LCA exists for a service, compliance with that LCD/LCA is required. Where Medicare guidance is absent, not applicable, or expressly allows flexibility, UnitedHealthcare applies its internal criteria and refers providers to the referenced UnitedHealthcare commercial medical policies for coverage guidance. The policy is informational and does not replace the member-specific benefit plan document; benefit coverage and payment are determined by the member's plan and applicable laws, and coverage may vary by member.

LCD/LCA: Local Coverage Determination / Local Coverage Article issued by Medicare Administrative Contractors that govern coverage in specific jurisdictions.

Revision History

2026-05-01revised_coverage_rationaleLatest

Coverage Rationale for Computer-Assisted Surgical Navigation for Musculoskeletal Procedures revised to indicate LCDs/LCAs exist and compliance is required where applicable; cross-reference added to UnitedHealthcare Commercial Medical Policy for states without LCDs/LCAs and direction to CMS Related Documents table for specific LCDs/LCAs.

2026-05-01edited_applicable_codesLatest

Applicable Codes section edited to remove the instruction to refer to the UnitedHealthcare Commercial Medical Policy for CPT code 20985.