CurrentKaiser PermanentePolicy 07/14/2016

Clinical Review Criteria Robotic Assisted Surgeries (RAS)

Defines Kaiser Permanente's clinical review criteria and reimbursement stance for robotic assisted surgery (RAS) and related procedure codes for Kaiser Foundation Health Plan of Washington and its Options, Inc.; applies to providers requesting coverage or review of RAS services.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Robotic Assisted Surgeries (RAS)

Policy CodePolicy 07/14/2016

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization and include the last 6 months of clinical notes when requesting review for robotic assisted surgery services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not separately reimbursedRAS and related CPT/HCPCS codes

RetiredMedicare LCDs

ListProcedures where RAS used

Last 6 months notesRequested documentation

Coverage criteria and policy stance

Coverage stance for robotic assisted surgery

Coverage and reimbursement position

Primary stance: Kaiser Permanente will not separately reimburse for the use of robotic surgical systems; requests for additional reimbursement for listed CPT/HCPCS codes are not separately payable.

Applies to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

The following CPT/HCPCS codes are not separately reimbursed when billed in association with a primary surgical procedure: 20985, 0054T, 0055T, S2900. This list may not be all-inclusive; deleted codes and codes not in effect at the time of service may not be covered.

A Washington State Health Care Authority evidence review found the available evidence for many procedures using robotic systems to be minimal. Based on that review, the Authority concluded there was insufficient justification to pay additional reimbursement specifically for use of the robotic device. Kaiser Permanente follows this assessment and does not separately reimburse for robotic system use.

Procedure and HCPCS/CPT coding

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Robotic Assisted Surgeries (RAS)

Policy CodePolicy 07/14/2016

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization and include the last 6 months of clinical notes when requesting review for robotic assisted surgery services.

SourceLink

On This Page

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Provider requirements, prior auth, and billing guidance

Prior Authorization

Prior Authorization Required

Prior authorization/review is required for robotic-assisted surgical services. Kaiser Permanente will not separately reimburse for the use of robotic surgical systems.

Affected codes may include (not all-inclusive): 20985, 0054T, 0055T, S2900 and related CPT/HCPCS codes.
Requests for additional separate reimbursement for robotic systems or the listed codes may be denied.
For high‑tech radiology (imaging) procedures requested for the purpose of robotic‑assisted surgery, refer to the High‑End Imaging Site of Care Policy.

Documentation Required

Required Documentation for Review

When requesting review, include the last 6 months of clinical notes from the requesting provider and/or specialist. Submit all documentation necessary to support medical necessity per Kaiser Permanente review requirements.

Include last 6 months of clinical notes from requesting provider and/or specialist.

Denial Risk

Separate Reimbursement Denial Risk

Requests for separate reimbursement for robotic surgical systems or listed codes may be denied; do not expect separate payment in addition to the primary procedure payment.

Do not bill for robotic system use separately; separate reimbursement requests may be denied.
Codes listed are illustrative and not exhaustive; deleted or retired codes may not be covered.

Note

Provider Action

Refer to the Kaiser Permanente payment policy for reimbursement clarifications and to relevant site‑of‑care policies for imaging related to robotic procedures.

Check the Kaiser Permanente payment policy for any reimbursement questions.
For imaging requests tied to robotic surgery, follow the High‑End Imaging Site of Care Policy.

Background and context

Robotic assisted surgery involves a computerized system operated by a surgeon at a console that controls robotic arms to perform or assist with laparoscopic procedures. These systems can allow finer, more precise control of instruments, although procedures may take longer than conventional approaches. Laparoscopic techniques in general are associated with reduced postoperative pain, faster recovery, and lower risk of infection and blood loss compared with open surgery for some procedures. The da Vinci system and other FDA-cleared platforms have been approved for multiple indications (for example, urologic and gynecologic laparoscopic procedures), but professional guidance and evidence do not establish robotic approaches as uniformly superior to less costly minimally invasive alternatives.

Definitions

Robotic assisted surgery — key definitions

TermRobotic assisted surgery

DefinitionUse of a computerized system operated by a surgeon at a console connected with robotic arms to assist in laparoscopic surgical procedures.

Clinical contextMay allow finer, more precise instrument control but can increase operative time; laparoscopic approaches may reduce postoperative pain, recovery time, infection risk, and blood loss versus open surgery for some procedures.

Regulatory/technology exampleFDA cleared systems (e.g., da Vinci) for general laparoscopic and multiple other indications since 2000.

Evidence summaryWashington State Health Care Authority found minimal evidence for many procedures and concluded not to pay additionally for robotic device use.

20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure).
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).
S2900	Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure).