CurrentUnitedHealthcarePolicy CS167PA.H

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

Policy governs use and coverage of computer-assisted surgical navigation (CAN/CAS) and intra-operative sensors for musculoskeletal procedures in Pennsylvania; applies to requests for these services and outlines coverage rationale, coding, and clinical evidence considered.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167PA.H

Change TypeNon-material revision (archived prior version CS167PA.Gupdated evidence and references)

Effective DateApril 1, 2026

Next Review DateN/A

Key ActionFor Pennsylvania requests, follow this Medical Policy and document device use and plan-specific contractual requirements when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

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

Pennsylvania-onlystate applicability

Unproven/not coveredcoverage stance

3 listednavigation codes cited

Multiple SRs & RCTsevidence sources

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Coverage Criteria and Clinical Conclusions

Not medically necessary — pelvis and appendicular skeleton; intra-operative sensors for knee arthroplasty

Covered when ALL of the following are met:

Primary stance: 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 CAN for pelvis and appendicular skeleton; intra-operative sensors for implant stability during knee replacement arthroplasty and for improved knee function post-operatively are also unproven and not medically necessary.

Evidence summaries and clinical conclusions

Evidence synthesis and conclusions from the literature relevant to CAN and intraoperative sensors include:

Knee CAN evidence: Multiple systematic reviews and randomized controlled trials (including a subgroup of 50 navigation-related RCTs in a large TKA review) show CAN frequently improves radiographic alignment but generally does not improve clinical outcomes; most RCTs report no significant differences in patient-centered outcomes. The AAOS guideline states there is 'strong evidence' to support not using intraoperative navigation in TKA because there is no difference in outcomes or complications.

Sources include Matar et al. (2020), Hayes comparative review, and AAOS guideline (2016, updated 2023).

Image-based CAN considerations: Image-based CAN (CT-based) may offer alignment advantages but is associated with greater expense, longer preoperative planning and operative time, and increased radiation exposure; clinical benefit over imageless CAN is unclear.

Hayes review and Panjwani meta-analysis findings.

Other appendicular and axial indications: Preliminary and small randomized or case-series studies suggest improved precision for select upper-extremity and other appendicular procedures, but there is insufficient evidence that this precision leads to improved clinical outcomes; larger controlled studies measuring health outcomes are needed.

Small RCTs (e.g., Pan et al. 2022) and limited case series reported trends but lacked statistical support for clinical benefit.

TKA intraoperative sensors: Systematic reviews, meta-analyses, RCTs, and case series show intraoperative sensors reduce measured compartmental imbalance and may reduce some interventions (for example, lower rates of manipulation under anesthesia in some analyses) but consistently fail to demonstrate statistically significant improvements in patient-reported functional outcomes, complication rates, or satisfaction at one year; overall evidence is insufficient to establish clinical benefit.

Evidence sources include Tran et al. (2025), Sun et al. (2022), Wood et al. (2021), Gustke and others; limitations include heterogeneity, short follow-up, and low-quality comparative data.

This policy addresses computer-assisted surgical navigation for pelvic and appendicular musculoskeletal procedures and related coding. For cranial and spinal procedures, refer to CPT codes 61781, 61782, or 61783; those indications are outside the scope of this policy. The navigation codes cited for pelvic and appendicular procedures include 0054T, 0055T, and 20985, and an unlisted code 27599 is noted as an example for devices such as intra-operative sensors.

The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for surgical management of osteoarthritis of the knee state there is strong evidence supporting not using intraoperative navigation in total knee arthroplasty (TKA) because studies show no difference in outcomes or complications (2016 guideline, updated 2023).

UnitedHealthcare considers computer-assisted surgical navigation (CAN/CAS) for procedures of the pelvis and appendicular skeleton to be not medically necessary and unproven due to insufficient evidence of clinical benefit. Similarly, the use of intra-operative sensors to assess implant stability during knee arthroplasty is considered not medically necessary; sensor use is regarded as incidental to the primary procedure and is not eligible for separate reimbursement.

The AAOS guideline reiterates a strong conclusion against the use of intraoperative navigation in TKA, emphasizing that available evidence demonstrates no improvement in clinical outcomes or reduction in complications when navigation is used for total knee arthroplasty (2016, updated 2023).

Procedure, CPT and Regulatory Codes

Navigation and related 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)

Regulatory clearances mentionedmixed

FDA 510(k)

Regulatory clearance pathway for many CAN devices (informational, not a billing code)

Provider Requirements, Billing and Documentation

Prior Authorization

Pennsylvania Prior Authorization / Policy Applicability

This Medical Policy applies to the state of Pennsylvania. Any requests for services that do not meet criteria set in the Pennsylvania PARP will be evaluated on a case-by-case basis. Refer to Pennsylvania Exceptions, Pennsylvania Code, Title 55, Chapter 1101.

Documentation Required

Verify Benefit Plan Requirements

Verify the member's benefit plan, contract, and any federal or state mandates before rendering services. Benefit coverage is determined by federal, state, or contractual requirements and may differ from this Medical Policy. In the event of a conflict, the federal, state, or contractual requirements govern. Check eligibility, prior authorization requirements, and any plan-specific exclusions or limits.

Confirm member eligibility and benefits
Confirm whether prior authorization is required by the benefit plan or state contract

Background and Scope

Computer-assisted navigation (CAN/CAS) encompasses intraoperative systems that provide surgical guidance and positioning information using either image-based methods (preoperative CT or MRI, or intraoperative fluoroscopy) or imageless approaches (intraoperative kinematic and morphology mapping with optical or electromagnetic trackers).

Typical CAN workflows include three components: data acquisition (fluoroscopy, CT, or MRI images or surface/landmark mapping), registration and tracking (matching patient anatomy to the navigation model and tracking instruments and implants), and guided execution (real-time feedback to assist implant positioning and alignment).

Some CAN devices and intraoperative sensors have received FDA 510(k) clearance for use as surgical information or sensor systems; however, regulatory clearance is informational and does not establish clinical effectiveness or coverage.

Key Terms and Device Definitions

Appendicular Skeleton System — included bones/regions

Included regionsShoulder girdle, upper limbs, pelvic girdle, and lower limbs

System definitionPart of the musculoskeletal system providing form, support, stability, and movement via bones, muscles, cartilage, tendons, ligaments, and joints

Examples of bonesHumerus, radius, ulna, femur, tibia, fibula, scapula, clavicle, pelvis

Sensor (intra-operative) — definition and measured properties

DefinitionAn electronic device used intraoperatively to measure physical properties (e.g., force, torque, pressure, distance, speed, acceleration) and send data to an electronic processor to inform surgical decisions

Purpose in TKAProvides objective assessment of ligament and soft-tissue balancing and may monitor postimplantation performance and patient recovery