CurrentUnitedHealthcarePolicy CS167KY.06

Computer Assisted Surg Nav Musculoskeletal Procs Ky Cs

UnitedHealthcare medical policy CS167KY.06 for Kentucky governs coverage of computer-assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton and intra-operative sensors for total knee arthroplasty (TKA), providing definitions, evidence review, coding clarifications, and an explicit coverage rationale.

Policy Summary

PayerUnitedHealthcare

PolicyComputer Assisted Surg Nav Musculoskeletal Procs Ky Cs

Policy CodePolicy CS167KY.06

Change TypeSupporting information update (Description of Services, Clinical Evidence, References)

Effective DateApr 1, 2026

Next Review Date

Key ActionIntra-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.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

2Primary not medically necessary statements (CAN and TKA sensors)

4Key CPT codes listed

updatedReferences

1Policy revision entry (04/01/2026)

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Coverage Summary & Rationale

Not covered / cosmetic This policy (UnitedHealthcare Medical Policy CS167KY.06) for the state of Kentucky addresses coverage of computer-assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton and intra-operative sensors used during total knee arthroplasty (TKA). Effective date: 2026-04-01. Coverage stance: Not covered / cosmetic — CAN/CAS and intra-operative sensors for the indications described are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Policy Metadata / Quick Facts

Policy NumberCS167KY.06

SubjectComputer-assisted surgical navigation and intra-operative sensors for musculoskeletal procedures (Kentucky only)

Effective Date2026-04-01

JurisdictionKentucky

StatusCURRENT

Primary not medically necessary statements (CAN and TKA sensors)2

Key CPT codes listed4

Referencesreferences updated

Policy revision entry (04/01/2026)1

Coverage Rationale / Medical Necessity Determination

Computer-assisted surgical navigation and intra-operative sensors are considered unproven and not medically necessary due to insufficient evidence of efficacy for the following:

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.
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.

ref

title

Medical Necessity Details

Coverage Rationale / Medical Necessity Determination

NOT MEDICALLY NECESSARY: 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.

NOT MEDICALLY NECESSARY: 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 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.

Computer-assisted navigation (CAN/CAS) refers to computer-enabled tracking systems — image-based (CT, MRI, fluoroscopy) or imageless — used intraoperatively to assist alignment and implant positioning in orthopedic procedures. Intraoperative sensors (for example, kinetic/load sensors used in TKA) provide objective measurements of ligament and soft-tissue balance and may offer intraoperative feedback to guide balancing maneuvers and postoperative monitoring, but evidence is currently insufficient to demonstrate improved patient-centered outcomes.

Coding — CPT cross-reference

Covered/Referenced navigational procedure codes (listed for reference only)CPT

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)

Cranial and spinal navigational CPT cross-referenceCPT

61781	Referenced for cranial procedures (not the focus of this policy).
61782	Referenced for cranial procedures (not the focus of this policy).
61783	Referenced for cranial procedures (not the focus of this policy).

Billing, Documentation & Operational Notes

Billing Rule

Sensor use considered incidental

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.

0054T
0055T
20985
27599

Documentation Required

Coding reference and disclaimer

The listed procedure and diagnosis codes are provided for reference only; listing of a code does not imply the service is covered or reimbursed. Benefit coverage is determined by federal, state, contractual requirements and applicable laws.

Background & Evidence Summary

Background: CAN/CAS systems perform three core functions: data acquisition (via fluoroscopy, CT, MRI, or imageless systems), registration (relating imaging or mapped anatomy to the surgical field), and tracking (real-time monitoring of tool and implant position using optical or electromagnetic trackers). In orthopedics, CAN/CAS aims to improve alignment and implant placement accuracy (originally developed for TKA and THA). Sensors are electronic devices that measure physical properties (force, pressure, distance, etc.) and, when used intraoperatively (eg, kinetic sensors), can quantify ligament/soft-tissue balance during TKA and may provide postimplantation performance data, though clinical outcome benefits remain unproven.

Evidence Item	Summary
Overall evidence conclusion	Insufficient evidence that computer-assisted navigation (CAN) or intra-operative sensors improve patient-centered outcomes; some studies show improved radiographic accuracy but no consistent functional outcome or complication reduction.
Zhou et al. 2024 (VTS-assisted THA)	Multicenter RCT (n=113 analyzed) showed higher proportion of acetabular components in Lewinnek safe zone with VTS-assisted THA (93.1% vs 50.9%) and longer operative time; no differences in short-term functional scores or dislocation rates.
Systematic reviews/meta-analyses	Multiple systematic reviews and meta-analyses report improved radiographic alignment with CAN but longer operative times and no consistent improvement in clinical or long-term outcomes; evidence quality often low or inconclusive for patient-oriented outcomes.
TKA sensor meta-analysis (Tran et al. 2025)	Meta-analysis of 14 articles including 4 RCTs (667 knees) found no significant improvement in functional scores, complications, or postoperative ROM for sensor-guided versus manual balancing.
RCTs and systematic reviews referenced	Multiple RCTs and meta-analyses (2016–2025) assessing navigation-assisted vs conventional arthroplasty and sensor-guided knee balancing were cited; RCTs often show improved radiographic metrics but not improved patient-reported or complication outcomes.

Definitions

Scope-specific notes

Policy Revision History

2026-04-01policy_revisedLatest

Archived previous policy version CS167KY.05. Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.