ModifiedUnitedHealthcarePolicy CS167NE.J

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

Defines UnitedHealthcare coverage stance for computer-assisted surgical navigation (CAN) in musculoskeletal procedures in Nebraska, including intra-operative sensors for knee arthroplasty, and lists related coding and policy references.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167NE.J

Change TypeEvidence and references updatedprior version archived

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionVerify member benefit and any required prior authorization; document the primary procedure and any use of navigation or sensors to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information and archived previous policy version CS167NE.I.

Recent systematic reviews and meta-analyses (including Tran 2025 and Zhou 2024) and updated AAOS guideline citations were incorporated into the evidence summary.

Nebraska-onlyJurisdiction

Not medically necessaryCAN coverage stance

IncidentalKnee sensor reimbursement

0054T,0055T,20985,27599

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Strong evidence (no use)AAOS recommendation

Coverage Criteria for Computer-Assisted Navigation and Intraoperative Sensors

Not medically necessary: CAN for pelvis and appendicular skeleton

Covered when ALL of the following are met:

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.

Applies to Nebraska.

Not medically necessary: intra-operative sensors for TKA

Covered when ALL of the following are met:

Intra-operative sensor for 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.

Intra-operative sensor use is considered incidental to the primary procedure and not eligible for separate reimbursement.

Coverage rationale and evidence interpretation

Key evidence-based coverage rationale and interpretation:

Overall evidence summary: For total knee arthroplasty (TKA), computer-assisted navigation (CAN) and sensor-guided techniques demonstrate improved surrogate measures (for example, radiographic alignment or intraoperative compartmental load metrics) in some studies but do not consistently demonstrate improved patient-centered clinical outcomes, functional scores, or lower complication/revision rates across randomized trials and systematic reviews.

Supported by multiple systematic reviews and RCTs (including Matar et al. 2020 and Tran et al. 2025) and AAOS guideline conclusions.

Limitations and other indications: For other pelvis or appendicular skeletal indications (upper extremity, trauma/fractures, non-knee applications), available evidence is limited, preliminary, or retrospective; clinical benefit for those indications is unclear and additional controlled studies are needed.

Evidence base is small or observational; technology-specific and indication-specific outcomes are not established.

Guideline and high-quality review conclusions: The AAOS Clinical Practice Guideline provides strong evidence recommending not using intraoperative navigation in TKA because there is no difference in outcomes or complications; high-quality systematic reviews and meta-analyses similarly report no consistent clinical advantage of CAN or sensor-guided balancing over conventional techniques.

For cranial and spinal procedures, providers should refer to CPT codes 61781, 61782, or 61783. The codes listed in this policy are intended for navigational procedures involving the pelvis and appendicular musculoskeletal system and include 0054T, 0055T, 20985, and 27599 as referenced examples.

This policy does not list explicit coverage exclusions beyond the clarification that evidence for non-knee indications is preliminary. The literature on CAN for upper extremity and axial skeleton (spine) is limited and early; small RCTs and retrospective cohort studies suggest potential improvements in procedural accuracy but do not demonstrate clear patient-centered clinical benefit, so further controlled studies measuring health outcomes are needed.

In spine-specific analyses, large retrospective cohorts have not shown reductions in short-term complication, readmission, or revision rates with CAN, although use of navigation was associated with longer operations and higher resource use in some series.

UnitedHealthcare considers computer-assisted surgical navigation for musculoskeletal procedures of the pelvis and appendicular skeleton not medically necessary because current evidence is insufficient to demonstrate improved patient-centered outcomes.

The use of an intra-operative sensor for implant stability during knee replacement arthroplasty is considered not medically necessary and is considered incidental to the primary procedure; separate reimbursement is not eligible due to insufficient evidence of efficacy.

The AAOS Clinical Practice Guidelines state there is strong evidence supporting not using intraoperative navigation in total knee arthroplasty because studies show no difference in clinical outcomes or complication rates compared with conventional TKA.

Coding and Procedure Codes

Referenced CAN 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)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization requirements vary by plan and contract. Verify whether prior authorization is required with the member's benefit plan before scheduling procedures; do not assume coverage. If prior authorization is required, submit clinical documentation that supports medical necessity per the member's plan.

Verify prior authorization with member's plan/contract before scheduling
If required, submit supporting clinical documentation demonstrating medical necessity

Documentation Required

Documentation Expectations

Use documentation to show that the service is not investigational for the specific indication. For computer-assisted musculoskeletal surgical navigation and intra-operative implant sensors, include operative reports, indication for navigation or sensor use, and supporting evidence that meets the member's plan medical necessity criteria.

Include operative report and indication for use

Key Definitions

Appendicular Skeleton System definition

DefinitionIncludes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs (Anderson et al., 2022).

Anatomic scopeShoulder girdle, upper extremities, pelvic girdle, and lower extremities — i.e., all limbs and their girdles.

Policy contextApplies to musculoskeletal procedures involving the appendicular skeleton; CAN claims for appendicular skeleton procedures are addressed in this policy.

Musculoskeletal System definition

DefinitionProvides form, support, stability, and movement to the body; made up of bones, muscles, cartilage, tendons, ligaments, joints, and other connective tissue (NIH, 2023).

ComponentsBones of the skeleton, muscles, cartilage, tendons, ligaments, joints, and connective tissues.

Background on Computer-Assisted Navigation

Computer-assisted navigation (CAN) systems provide intraoperative guidance—either image-based or imageless—to assist implant positioning and alignment in procedures such as total hip and knee arthroplasty. While CAN can improve radiographic or intraoperative alignment measures in some studies, the evidence remains inconsistent and generally does not show a reliable improvement in patient-centered clinical outcomes across pelvis and appendicular indications; evidence outside hip and knee is preliminary and further controlled studies are needed.

Policy Revision History

2026-04-01policy_revisionLatest

Updated Description of Services, Clinical Evidence, and References sections; archived previous policy version CS167NE.I.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167NE.J

Change TypeEvidence and references updatedprior version archived

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionVerify member benefit and any required prior authorization; document the primary procedure and any use of navigation or sensors to support medical necessity.

SourceLink

On This Page

Guideline and systematic review findings inform the not medically necessary stance.

Provide supporting clinical evidence per plan medical necessity rules

Document that intra-operative sensor use is incidental to primary procedure if claiming incidental billing

Billing Rule

Coding and Reimbursement Notes

Separate reimbursement for intra‑operative implant sensors used during knee arthroplasty is generally not allowed; these devices are considered incidental to the primary procedure. Use of unlisted or Category III/II/other codes should be accompanied by detailed documentation and justification.

Do not separately bill for intra-operative sensor when it is incidental to knee arthroplasty
If billing an unlisted code (e.g., 27599) provide detailed operative documentation and rationale

Denial Risk

Denials are likely when documentation does not demonstrate medical necessity or when the service is specifically considered investigational or not medically necessary by UnitedHealthcare. For computer-assisted musculoskeletal navigation and intra-operative knee sensors, lack of evidence of efficacy increases denial risk.

High denial risk if documentation does not support medical necessity
Expect denial when procedure is listed as unproven/not medically necessary in the policy

Billing Rule

Coding Clarifications and Verification

Prior to submission, verify the applicable CPT/HCPCS codes and that the billing matches the procedure performed (e.g., 0054T, 0055T, 20985, or unlisted codes such as 27599). For cranial and spinal navigation, use CPT codes 61781–61783 and follow applicable policy guidance.

Confirm correct code selection: 0054T, 0055T, 20985, or 27599 where applicable
For cranial/spinal procedures, reference CPT 61781–61783 and related policy guidance

Note

Plan/Contract Verification Required

Always check the member's specific plan, federal/state mandates, and any contract language that may require coverage despite this policy. When in doubt, obtain prior authorization and provide full clinical rationale.

Verify plan/contract terms and state/federal mandates
Obtain prior authorization if uncertain and submit comprehensive clinical rationale

Policy relevanceServices directed at the musculoskeletal system (including CAN) are assessed for clinical outcome benefit in this policy.

Computer-assisted navigation (CAN) definition

DefinitionSurgical navigation systems that provide intraoperative guidance for implant placement and alignment; systems may be image-based (CT/MRI/fluoroscopy) or imageless and are generally cleared by the FDA via 510(k) as surgical information systems.

Typical componentsMay include preoperative imaging, intraoperative tracking hardware/software, and real-time display of instrument or implant position.

Clinical claimProposed benefits include improved component positioning and alignment accuracy, though evidence linking these surrogate outcomes to consistent patient-centered benefit is limited.

Intraoperative sensors / sensor-guided balancing definition

DefinitionDevices that measure compartmental loads during total knee arthroplasty to guide soft-tissue releases and aim to achieve target intercompartmental pressure balance (example: VERASENSE).

Intended functionProvide intraoperative quantitative feedback on medial/lateral compartment loads to help surgeons adjust balancing maneuvers.

Evidence summarySensor-guided balancing improves intraoperative balance metrics but randomized trials and meta-analyses have not consistently demonstrated improved patient-centered functional outcomes or lower complication rates.