ModifiedUnitedHealthcarePolicy CS167KY.06

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

This policy governs the medical necessity and coding for computer-assisted surgical navigation (CAN) and intra-operative sensors in musculoskeletal procedures for members in Kentucky; it applies to use in pelvic and appendicular skeleton procedures and to intra-operative sensors used during knee arthroplasty.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167KY.06

Change TypeSupporting information and clinical evidence updated

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization per UnitedHealthcare plan rules when required by the member's benefit.

SourceLink

POLICY UPDATE CHANGES

Updated supporting information, description of services, clinical evidence, and references sections to reflect the most current information.

Pelvis & appendicularAnatomic scope deemed unproven

Not medically necessarySensor use (knee)

0054T,0055T,20985,27599Procedure codes discussed

KentuckyGeographic applicability

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Common comparative finding

Coverage Criteria and Rationale

Not medically necessary determinations

Covered when ALL of the following apply:

Primary coverage determination: 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.

Supports denial of coverage for these anatomic uses.

Sensor use during knee arthroplasty: 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.

Sensor use considered incidental and not separately reimbursable.

Coverage rationale (evidence-based summaries)

Summary of evidence-based stance reflected in the clinical sections:

Evidence summary for CAN in TKA: Randomized trials and meta-analyses generally show no consistent improvement in mid- to long-term clinical outcomes or complications for computer-assisted navigation (CAN) versus conventional total knee arthroplasty (TKA); some studies report improved radiologic alignment but this has not translated into consistent patient-centered benefit.

Includes findings from large systematic reviews and meta-analyses.

Evidence summary for sensor-guided TKA: Intraoperative sensors improve intraoperative balance metrics and reduce the proportion of 'unbalanced' knees in some trials, but randomized trials and meta-analyses have not demonstrated consistent improvements in functional scores, range of motion, complication or reoperation rates, or patient satisfaction compared with manual techniques.

High-quality, long-term RCT evidence is lacking; further trials recommended.

Other appendicular/pelvic indications: CAN may improve precision of bone cutting and implant placement in hip and other appendicular/pelvic procedures and small trials show improved accuracy in some anatomic outcomes, but clinical outcome benefit (patient function, complications, long-term survivorship) is unclear and evidence is preliminary.

FDA clearance via 510(k) has been granted for multiple systems, but 510(k) clearance does not by itself demonstrate improved health outcomes.

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. This coding clarification indicates the sensor is part of the primary TKA service and should not be billed or reimbursed independently from the primary procedure.

There are no explicit population- or indication-based exclusions listed in this policy; however, the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines state strong evidence supporting not using intraoperative navigation in total knee arthroplasty because studies show no difference in outcomes or complications. Where plan coverage requires guideline-concordant care, this guideline context may affect coverage decisions.

Computer-assisted surgical navigation (CAN) for musculoskeletal procedures of the pelvis and appendicular skeleton is considered unproven and not medically necessary due to insufficient evidence of clinical efficacy. Similarly, intra-operative sensors used to assess implant stability during knee arthroplasty are considered unproven and not medically necessary. Evidence to date suggests CAN may improve procedural precision in some settings, but improved patient-centered outcomes have not been demonstrated, and therefore coverage for these anatomic uses and sensor applications is not supported.

Routine use of computer-assisted navigation or intraoperative sensor systems in primary total knee arthroplasty (TKA) is not supported by high-quality evidence demonstrating improved patient-centered outcomes. Systematic reviews and randomized trials have not consistently shown better mid- to long-term clinical outcomes, functional scores, or complication reductions versus conventional techniques, and AAOS guidance also advises against routine intraoperative navigation in TKA.

Procedure Codes and Coding Guidance

Navigational procedure codes and example unlisted codeCPT

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)

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required in accordance with the member’s benefit plan and UnitedHealthcare prior authorization rules. Prior authorization may be required for computer-assisted navigation (CAN) procedures and intra-operative sensors when the codes listed in this policy are billed or when plan rules indicate prior authorization for musculoskeletal surgical adjuncts.

Follow the member’s contract and plan-specific prior authorization procedures.
When in doubt, obtain prior authorization before performing CAN or using intra-operative sensors to avoid claim denials.

Denial Risk

Coverage Stance: CAN and Intra‑operative Sensors

Coverage for computer-assisted surgical navigation (CAN) for musculoskeletal procedures of the pelvis and appendicular skeleton and for intra-operative sensors used to assess implant stability during knee arthroplasty is not supported by sufficient evidence and is considered unproven and not medically necessary.

Background and Clinical Context

Computer-assisted navigation (CAN) encompasses image-based and imageless systems that provide intraoperative guidance for implant alignment and bone cutting. Typical components include data acquisition (fluoroscopy, CT/MRI, or imageless approaches), registration that maps imaging or anatomy to the patient, and tracking using optical or electromagnetic sensors. While many CAN systems have received FDA 510(k) clearance and may improve technical accuracy, available evidence has not consistently demonstrated corresponding improvements in patient-oriented clinical outcomes.

Definitions

Appendicular Skeleton System — definition/contents

DefinitionIncludes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs.

Scope (examples)Shoulder girdle, humerus, radius, ulna, carpals/metacarpals, pelvic girdle, femur, tibia, fibula, tarsals/metatarsals.

ContrastDistinct from the axial skeleton (skull, vertebrae, ribs, sternum); pertains to limbs and their girdles.

Sensor (intra-operative/postimplant) — definition

DefinitionAn electronic device that measures physical properties (e.g., pressure, force, distance, torque) and transmits data to an electronic processor; used intraoperatively to provide objective assessment of ligament and soft-tissue balancing and postimplantation to monitor implant performance.

Intraoperative use

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167KY.06

Change TypeSupporting information and clinical evidence updated

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization per UnitedHealthcare plan rules when required by the member's benefit.

SourceLink

On This Page

CAN for pelvic and appendicular musculoskeletal procedures — Not medically necessary.
Intra-operative sensor for implant stability during total knee arthroplasty — Not medically necessary.

Prior Authorization

Prior Authorization per Plan Rules

Prior authorization and coverage decisions follow plan rules and federal/state/contractual requirements. This policy is informational; always verify coverage requirements in the member's contract. If contractual or regulatory requirements differ from this policy, those requirements govern.

Obtain prior authorization per the member’s plan when required by that plan.
Use InterQual and applicable UnitedHealthcare guidelines when determining medical necessity if referenced by the benefit plan.

Denial Risk

Guideline‑Based Denial Risk

Use guideline recommendations to anticipate denial risk. AAOS guidance states there is strong evidence against using intraoperative navigation in total knee arthroplasty because outcomes and complications do not improve; this supports medical necessity denial risk for CAN and intra-operative navigation devices in TKA.

AAOS Clinical Practice Guideline (knee OA/TKA) — strong evidence against intraoperative navigation.
Expect guideline-based denials when documentation does not support improved outcomes or medical necessity.

Documentation Required

Documentation and Reimbursement Note

Document clinical rationale thoroughly when billing for navigational procedures or when intra-operative sensors are used. Include operative reports, indication, expected benefit, and any supporting evidence that justifies use beyond standard of care. For intra-operative sensors used during knee arthroplasty, document that the device was incidental to the primary procedure if no separate reimbursement is sought.

Include detailed operative note describing use of CAN or sensor and the clinical reason for its use.
Attach prior authorization determination when one was obtained.
If no separate reimbursement is sought for an incidental sensor, document that the sensor was part of the primary procedure.

Note

Device Clearance Documentation

Surgical navigation systems and intra-operative sensors listed in the FDA 510(k) database have received regulatory clearance, but FDA 510(k) clearance alone does not establish coverage or medical necessity.

FDA-cleared CAN devices include (not limited to): ExactechGPS, iASSIST, Intellijoint, KneeAlign, Verasense, Stryker Navigation System.
Search FDA 510(k) database for device-specific clearance details: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm

Denial Risk

Denial Risk for CAN and Intra‑operative Sensors

Intra-operative use of sensors for implant stability during knee replacement is considered incidental and not eligible for separate reimbursement; unlisted or add-on codes billed separately for sensors are at high risk of denial unless plan rules explicitly allow separate payment.

0054T, 0055T, 20985 — intended for musculoskeletal navigational procedures (pelvic/appendicular).
27599 — unlisted procedure (e.g., sensor) is typically not separately reimbursed for incidental intra‑operative use.

Billing Rule

Coding and Billing Clarification

Codes and coding clarifications in this policy are provided for reference only; inclusion does not guarantee coverage or reimbursement. Verify coding guidance with the member’s plan and submit operative documentation to support any billed codes.

Coding clarifications: intra-operative sensor use considered incidental to primary procedure and not eligible for separate reimbursement.
Refer cranial and spinal navigation to CPT 61781-61783 as appropriate.

Note

Operational Note

Before relying on this policy, review the member’s contract and any federal/state mandates. This policy may be updated; see Policy History for revision dates and changes.

Policy effective date: 2026-04-01.
Review plan-specific coverage rules and authorization processes prior to providing services.

Provides real-time data on ligament/soft-tissue balance during procedures such as total knee arthroplasty (TKA).

Postimplant applicationCan provide postimplantation data to monitor implant performance and patient recovery during rehabilitation.

Computer-assisted navigation (CAN) — definition and FDA clearance mention

DefinitionSurgical information systems that provide intraoperative guidance for implant alignment or bone cutting using image-based or imageless tracking, registration, and real-time tool tracking.

Data & functionsTypical CAN functions include data acquisition (fluoroscopy/CT/MRI or imageless), registration (mapping images to patient anatomy), and tracking (optical or electromagnetic trackers).

Regulatory statusA variety of CAN devices have received FDA 510(k) clearance; FDA treats CAS as a surgical information system and generally requires 510(k) clearance rather than premarket approval.

Sensor-guided gap balancing — definition and examples

DefinitionUse of intraoperative kinetic/load-sensing devices to provide real-time compartment pressure or load data to guide soft-tissue releases and balancing during TKA (examples include VERASENSE/Verasense Knee System).

Clinical purposeAims to quantify intercompartmental loads and guide adjustments to achieve target balance (e.g., within 15 pounds intercompartmental pressure variance in some trials).

Examples & evidenceDevices cited include VERASENSE; RCTs (e.g., Wood et al.) showed improved intraoperative balance metrics but no consistent improvement in 1-year clinical outcomes or patient satisfaction based on available trials and meta-analyses.