CurrentUnitedHealthcarePolicy CS167KY.05

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Kentucky Only)

UnitedHealthcare Kentucky medical policy CS167KY.05 governs coverage of computer-assisted surgical navigation (CAN) for musculoskeletal procedures of the pelvis and appendicular skeleton, and intra-operative sensors for implant stability during total knee arthroplasty (TKA). It applies only to Kentucky and provides coverage rationale, applicable codes, definitions, evidence summary, and coding/billing clarifications.

Policy Summary

PayerUnitedHealthcare

PolicyComputer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Kentucky Only)

Policy CodePolicy CS167KY.05

Change TypeRevised language; removed reference link

Effective DateMar 1, 2025

Next Review Date

Key ActionReport intra-operative sensor use for implant stability during TKA as incidental to the primary procedure; it is not eligible for separate reimbursement.

POLICY UPDATE CHANGES

Replaced language about intra-operative kinetic balance sensor to state 'the use of an intra-operative sensor for implant stability during knee replacement arthroplasty and for improved knee function post-operatively is unproven and not medically necessary.'

Removed reference link to the Reimbursement Policy titled Robotic Assisted Surgery Policy, Professional.

2Primary technologies addressed (navigation, sensors)

KentuckyGeographic scope

Not medically necessary

Coverage Summary

Policy CS167KY.05 (effective 2025-03-01, last reviewed 2025-03-01) applies to UnitedHealthcare members in Kentucky only and covers computer-assisted surgical navigation (CAN) for musculoskeletal procedures of the pelvis and appendicular skeleton and intra-operative sensors used for implant stability during total knee arthroplasty (TKA). The policy stance is not medically necessary for CAN of the pelvis and appendicular skeleton and for the use of an intra-operative sensor for implant stability and for improved knee function post-operatively, citing insufficient evidence of efficacy. Primary technologies addressed include navigation systems (image-based and imageless CAN) and sensors (intraoperative kinetic/force sensors and wearable/postimplantation sensors).

Key facts

Geographic scopeKentucky only

Policy numberCS167KY.05

Effective date2025-03-01

Last review2025-03-01

Coverage stanceNot medically necessary

Primary technologies addressed2 (navigation, sensors)

Medical Necessity / Not Medically Necessary

Medically Necessary / Not Medically Necessary

Coverage determination for CAN and intra-operative sensors:

ALL of the following

Computer-assisted surgical navigation for musculoskeletal procedures of the pelvis and appendicular skeleton is unproven and not medically necessary due to insufficient evidence of efficacy.
Applies to pelvis and appendicular skeleton (includes shoulder girdle, upper limbs, pelvic girdle, lower limbs).
The use of an intra-operative sensor for implant stability during knee replacement arthroplasty and for improved knee function post-operatively is unproven and not medically necessary due to insufficient evidence of efficacy.
Intra-operative sensor considered incidental to primary procedure and not eligible for separate reimbursement.

Coding

Referenced navigation procedure codesCPT

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., sensor).

Policy revision note: the description for CPT 27599 was revised and incidental reimbursement language was clarified — intra-operative use of a sensor for implant stability during knee replacement arthroplasty is considered incidental to the primary procedure and is not eligible for separate reimbursement.

Provider Actions / Billing Guidance

Billing Rule

No separate reimbursement for intra-operative sensor in TKA

Intra-operative use of a sensor for implant stability during knee replacement arthroplasty is considered incidental to the primary procedure and is not eligible for separate reimbursement; report as incidental to the primary procedure.

27599
0054T
0055T
20985

Documentation Required

State applicability

This policy applies only to UnitedHealthcare members in the state of Kentucky; verify state-specific benefit plan and contractual requirements when making coverage decisions.

Background & Evidence Summary

Computer-assisted navigation (CAN) systems provide image-based or imageless guidance for data acquisition, registration, and tracking to assist implant positioning and alignment in a range of orthopedic procedures. Sensors (for example, VERASENSE) can provide intraoperative kinetic data to guide ligament balancing and can also supply post-implantation performance or gait data. Multiple CAN and sensor devices have received FDA 510(k) clearance, but randomized trials and meta-analyses show improved radiographic accuracy or intraoperative balancing without consistent evidence of improved patient-centered outcomes, reduced complications, or fewer revisions; operative times are frequently longer and clinical outcome benefits remain limited and inconsistent.

Evidence type	Summary
RCT/meta-analysis findings	Multiple RCTs and meta-analyses report improved radiographic/component alignment with CAN but no consistent improvement in clinical outcomes or reduced complications/revisions; CAN often increases operative time.
Sensor evidence	Sensor-guided balancing reduces intraoperative unbalanced knees and can decrease some interventions (eg, fewer manipulations under anesthesia) but RCTs and meta-analyses do not consistently show improved patient-reported outcomes or reduced reoperation rates.

Appendicular Skeleton System: Includes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs.

Musculoskeletal System: Made up of the bones of the skeleton, muscles, cartilage, tendons, ligaments, joints, and other connective tissue that supports and binds tissues and organs together.

Revision History

2025-03-01material_revisionLatest

Revised policy language to state that 'the use of an intra-operative sensor for implant stability during knee replacement arthroplasty and for improved knee function post-operatively is unproven and not medically necessary.' Also revised description for CPT code 27599 and clarified incidental reimbursement language to indicate intra-operative use of a sensor is considered incidental to the primary procedure and not eligible for separate reimbursement.

2025-03-01non_material_removal

Removed reference link to the Reimbursement Policy titled 'Robotic Assisted Surgery Policy, Professional.'