Modifiedpriority healthPolicy NO. 91641

COMPUTER ASSISTED SURGICAL NAVIGATION

Defines medical necessity and coverage stance for computer assisted surgical navigation (CAN) procedures, including pulmonary (bronchoscopy) and orthopedic/musculoskeletal applications, for Priority Health members.

Policy Summary

Payerpriority health

PolicyComputer Assisted Surgical Navigation

Policy CodePolicy NO. 91641

Change TypeExclusion addedbackground updated

Effective DateJun 1, 2026

Next Review Date

Key ActionSubmit prior authorization when required by the member's plan demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added exclusion for ENT, cranial/maxillofacial, and neurosurgery procedures

Updated background and references

85.2%pooled diagnostic yield

1.18%pneumothorax rate

8procedure codes listed

May/Jun 2026committee review

Coverage Criteria — Medical Necessity & Exclusions

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Medically necessary indications

Covered when the following conditions apply:

Pulmonary Procedures: Computer assisted navigation bronchoscopy procedures (robotic and electromagnetic navigational bronchoscopy) are considered medically necessary when performed in accordance with National Comprehensive Cancer Network (NCCN) Non-Small Cell Lung Cancer guidelines.

References NCCN guidelines

Pulmonary Procedures - Investigational: All other computer assisted navigation bronchoscopy procedures are considered experimental and investigational.

Investigational when not in accordance with NCCN NSCLC guidelines

Orthopedic/Musculoskeletal Procedures: Surgical navigation for use in orthopedic indications (spinal, cranial, and other musculoskeletal procedures) may be considered medically necessary when applicable TurningPoint criteria are met.

Requires review against TurningPoint criteria via Priority Health Prism

Not medically necessary indications

Not covered for other indications:

Other Indications: Computer assisted surgical navigation for all other indications, including but not limited to ear, nose and throat (ENT), maxillofacial, and neurosurgery procedures, is considered not medically necessary.

Explicit exclusion list

Computer-assisted surgical navigation (CAN) is covered only for the indications specifically listed in this policy — namely pulmonary procedures (computer-assisted navigation bronchoscopy) and orthopedic/musculoskeletal surgical navigation when the applicable medical necessity criteria are met. CAN performed for indications other than these listed pulmonary and orthopedic/musculoskeletal procedures is considered not medically necessary and is not covered.

An operational exclusion has been added to this policy that specifically removes coverage for CAN when used for ear, nose, and throat (ENT), cranial/maxillofacial, and neurosurgery procedures. Claims for procedures in these categories should be processed in accordance with the exclusion and may be denied under the terms of this policy.

Coding — CPT / HCPCS

CPT/HCPCS codes listedCPT

31627	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s])
C7567	Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i), with computer-assisted image-guided navigation.
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure).
61781	Stereotactic navigation, cranial intradural.
61782	Stereotactic navigation, cranial extradural.
61783	Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure).
0054T	Computer-Assisted Musculoskeletal Surgical Naviational Orthopedic Procedure Guidance Based On Fluroscopic Images.
0055T	Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure Guidance Based On CT/MRI Images.

Provider Actions — Authorization, Documentation, Billing Notes

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain drugs, devices, services and procedures. When prior authorization is required, providers must submit a request demonstrating that the service or procedure is medically necessary per Priority Health guidelines. Refer to the Priority Health Provider Manual for details and access TurningPoint guidelines via Priority Health Prism → Authorizations → Authorization Criteria Lookup.

Providers must submit prior authorization when required and include supporting documentation showing medical necessity.
Individual case review may allow coverage for promising investigational treatments only with prior plan approval; determinations are made by a Priority Health medical director or clinical pharmacist.
No step therapy requirements apply to the procedures covered by this policy.

Denial Risk

Exclusion Added — ENT / Cranial/Maxillofacial / Neurosurgery

An exclusion has been added: computer-assisted surgical navigation (CAN) for ear, nose and throat (ENT), cranial/maxillofacial, and neurosurgery procedures is considered not medically necessary. Claims for CAN in these specialties may be denied as excluded services and require no further medical-necessity review under this policy.

Excluded specialties: ENT, cranial/maxillofacial, neurosurgery — CAN considered not medically necessary.
Prior authorization implications: Requests for CAN in the excluded specialties should not be submitted for coverage consideration under this policy; claims may be denied per the exclusion.

Documentation Required

Prior Authorization and Documentation

When prior authorization is required, submit complete documentation. For requests involving investigational or unproven treatments, prior plan approval is required and determinations will be made by a Priority Health medical director or clinical pharmacist. Providers should consult the Provider Manual for submission instructions.

Submit all clinical records and supporting rationale with the prior authorization request when required.
Investigational requests: must have prior plan approval and will be reviewed by a Priority Health medical director or clinical pharmacist.

Step Therapy

Providers should note there are no step therapy requirements associated with the covered indications in this policy. Follow normal authorization and documentation procedures when prior approval is required.

No step therapy requirements for procedures covered by this policy.

Note

Administrative Notes

Administrative notes: All CPT code data are copyrighted by the American Medical Association. The terms 'Priority Health' and 'plan' refer to Priority Health and its affiliated entities.

AMA CPT copyright applies to codes and descriptions.
The name 'Priority Health' and the term 'plan' include Priority Health, Priority Health Managed Benefits, Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc.

Background — Technology Overview

Computer-assisted surgery uses imaging and computer technology to create three-dimensional models and guidance information to support surgical procedures. In musculoskeletal applications, CAN is intended to improve surgical accuracy and reduce malposition by providing image-based or image-less navigation tied to the patient’s anatomy. Use of CAN in orthopedic and other musculoskeletal procedures is addressed in this policy only when the specific medical necessity criteria are satisfied.

Definitions — Key Terms

Stereotactic neurosurgery — definition entry

DefinitionStereotactic neurosurgery: a technique that uses computer technology, brain imaging, and a coordinate system (frame-based or frameless) to produce a 3‑D model of the brain to locate a lesion.

Coordinate system typesFrame-based (rigid mechanical frame) or frameless (reference points on the skull).

Primary purposeTo safely and precisely navigate to and treat brain tumors, vascular malformations, or other intracranial lesions, enabling resection with minimized risk to surrounding tissue.

Relation to CANStereotactic neurosurgery is a form of computer-assisted surgery (image-guided surgery) used in neurosurgical procedures.

Electromagnetic navigation bronchoscopy (ENB) — definition entry

DefinitionElectromagnetic navigation bronchoscopy (ENB): bronchoscopy that combines electromagnetic (EM) technology with a CT-generated digital representation of the patient's bronchial tree to navigate, access, and sample peripheral lung lesions.

How it worksAn EM field is generated around the patient's chest and a specialized EM sensor tracks the scope's position within that field, corroborated with real-time visualization and CT-derived airway maps.

Clinical applicationUsed to reach and biopsy hard-to-reach areas of the lungs not easily accessible with traditional bronchoscopy.

CategorizationClassified as a computer-assisted navigation bronchoscopy procedure within CAN technologies.

Shape-sensing robotic-assisted bronchoscopy (ssRAB) — definition entry

DefinitionShape‑sensing robotic‑assisted bronchoscopy (ssRAB): robotic bronchoscopy using a fiber embedded along the robotic catheter that provides real‑time shape and location information corroborated with CT scan–derived airway maps during navigation and specimen acquisition.

Technology specificsA shape‑sensing fiber in the catheter supplies continuous shape and position data; navigation is corroborated with CT airway maps throughout the procedure.

Relation to RAB typesssRAB is one form of robotic‑assisted bronchoscopy distinct from EM‑based RAB, which uses an external electromagnetic field generator and embedded sensors.

Clinical roleUsed for navigating to and sampling peripheral pulmonary nodules as part of CAN bronchoscopy procedures.

Navigation/AR-assisted surgery — definition entry

DefinitionNavigation/AR‑assisted surgery (computer‑assisted navigation, CAN or augmented reality‑assisted navigation): the use of imaging scans and computer technology to create 3‑D models and tracking systems to guide surgical procedures and improve accuracy.

ModalitiesCan be image‑based (preoperative CT, MRI, ultrasound, fluoroscopy) or non‑image‑based (using joint kinetics and bone morphology for planning).

Clinical goalsTo increase surgical accuracy, facilitate implant positioning or lesion targeting, and reduce malposition or injury to surrounding structures.

Scope of useApplied across musculoskeletal/orthopedic procedures and bronchoscopy; policy excludes use for ENT, maxillofacial, and neurosurgery indications outside specified coverage criteria.