CurrentUnitedHealthcarePolicy CS167NM.C

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for New Mexico Only)

Governs use and coverage of computer-assisted surgical navigation (CAN/CAS) and intra-operative implant stability sensors for musculoskeletal procedures in New Mexico; affects providers performing hip, pelvis, and knee musculoskeletal surgeries and associated billing.

Policy Summary

PayerUnitedHealthcare

PolicyComputer-Assisted Surgical Navigation for Musculoskeletal Procedures (for New Mexico Only)

Policy CodePolicy CS167NM.C

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionCheck plan-specific prior authorization requirements before proceeding and document device used and rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

New MexicoGeographic scope

0054T,0055T,20985,27599Key codes referenced

InsufficientEvidence stance

50 RCTsRCTs summarized

Coverage Criteria for CAN and Intraoperative Sensors

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General coverage determination — Pelvis and Appendicular Skeleton

Covered when ALL of the following are met

Primary coverage stance: Computer-assisted surgical navigation for musculoskeletal procedures of the pelvis and appendicular skeleton is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Policy states not medically necessary for these indications.

Sensor use during knee arthroplasty

Intra-operative sensor for knee arthroplasty: Use of an intra-operative sensor for implant stability during knee replacement arthroplasty and for improved knee function post-operatively is considered unproven and not medically necessary due to insufficient evidence of efficacy; intra-operative sensor use is considered incidental to the primary procedure and is not eligible for separate reimbursement.

References both clinical stance and coding clarification.

Navigation systems (Knee and other musculoskeletal indications)

Summary of evidence-based coverage considerations

Navigation systems - evidence summary: CAN may improve implant alignment in some studies, but randomized trials and meta-analyses generally show no consistent improvement in clinical outcomes (function, complications, long-term benefit) compared with conventional techniques; AAOS guideline evidence recommends against routine intraoperative navigation in TKA because outcomes are not improved. Image-based CAN has disadvantages (greater expense, longer operative time, radiation) and no clear clinical advantage over imageless CAN.

See cited systematic reviews, meta-analyses, and guideline statements.

Intraoperative kinetic/sensor devices for TKA

Sensor-assisted balancing evidence

Intraoperative sensors - evidence summary: Sensor-assisted balancing reduces intraoperative measures of imbalance and may lower some procedure-specific events in some series, but pooled randomized trial evidence and meta-analyses do not demonstrate consistent, statistically significant improvements in functional scores, complication rates, or patient satisfaction at typical follow-up intervals; additional high-quality, long-term RCTs are needed.

See systematic review/meta-analysis and RCTs (Tran et al., Wood et al.) and case series for details.

Non-knee orthopaedic uses of CAN

Navigation for other pelvis and appendicular skeletal procedures

Other musculoskeletal indications: Preliminary and small randomized or cohort studies suggest CAN may improve the precision of bone cuts or implant placement (for example in shoulder, elbow, trauma, or pelvic applications), but evidence is insufficient to demonstrate improved patient-level health outcomes; further controlled studies with clinical outcome measures are required before routine coverage can be supported.

See small RCTs and cohort studies referenced.

Separate reimbursement for intra-operative use of a sensor for implant stability during knee replacement arthroplasty is excluded. Per the policy coding clarifications, intra-operative sensor use is considered incidental to the primary procedure and therefore not eligible for separate reimbursement.

FDA 510(k) clearance or other FDA notification for a navigation or sensor device is provided for informational purposes only and does not establish coverage. The policy notes that surgical navigation systems are typically cleared via the 510(k) pathway and that the FDA does not require data demonstrating intermediate or final health outcomes for these devices; therefore FDA clearance alone is not a basis for coverage.

Computer-assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton is considered not medically necessary due to insufficient evidence of efficacy. Claims for CAN in these indications may be denied on that basis, as the policy concludes that available evidence does not demonstrate improved health outcomes for these anatomic regions.

Use of intra-operative sensors to assess implant stability or guide ligament balancing during total knee arthroplasty (TKA) is considered unproven and not medically necessary. The policy states sensors are incidental to the primary arthroplasty procedure and, while some studies show improvements in intraoperative balance measures, evidence is insufficient to demonstrate consistent improvements in post-operative knee function or other patient-centered outcomes.

Routine use of intraoperative navigation for total knee arthroplasty is not supported by current guideline and randomized-trial evidence. The AAOS Clinical Practice Guideline states there is strong evidence to support not using intraoperative navigation in TKA because it shows no difference in outcomes or complications, and multiple systematic reviews and RCTs similarly report no consistent clinical benefit despite some radiologic improvements.

Provider Actions, Billing, and Documentation

Prior Authorization

Prior authorization / coding headline

Prior authorization and coding: Check plan-specific prior authorization requirements and billing rules before scheduling. The following CPT codes are referenced for computer-assisted navigational procedures of the pelvis and appendicular skeleton: 0054T, 0055T, 20985 (list separately in addition to the code for the primary procedure). An unlisted code sometimes used for femur or knee procedures (e.g., sensor) is 27599. For cranial and spinal procedures, see CPT 61781–61783. Confirm any UnitedHealthcare plan-level authorization requirements as plan terms and applicable benefit contracts may vary.

Affected codes: 0054T, 0055T, 20985 (CAN navigation codes); 27599 (unlisted femur/knee, e.g., sensor)
For cranial/spinal navigation, refer to CPT 61781–61783
Verify UnitedHealthcare plan-specific prior authorization and benefit terms

Documentation Required

Documentation note on sensor use

Documentation should clearly state that intra-operative use of a sensor for implant stability during knee arthroplasty is incidental to the primary arthroplasty procedure. Per policy, intra-operative sensor use is not eligible for separate reimbursement; include operative notes describing the primary procedure, the sensor use as incidental, and clinical rationale for any intraoperative assessments performed.

Note: separate reimbursement for intra-operative sensors during knee arthroplasty is excluded
Document device role as incidental to the primary arthroplasty in operative report

Documentation Required

Device identification and supporting evidence

Device identification and supporting evidence: Providers should document the specific device used (manufacturer and device name) and the clinical rationale for use in the medical record. Although many computer-assisted navigation (CAN) systems have FDA 510(k) clearance, 510(k) clearance does not constitute evidence of improved clinical outcomes. Include citations to peer-reviewed evidence or rationale when asserting clinical necessity, and be prepared to supply device FDA 510(k) details if requested.

Record device manufacturer and model (e.g., ExactechGPS, iASSIST, Verasense, Intellijoint, etc.)
Note: FDA 510(k) clearance listed for many CAN devices does not by itself establish clinical benefit
Provide supporting clinical evidence or rationale in the chart when requesting coverage or explaining use

Note

Provider action: follow UnitedHealthcare plan terms and confirm any required prior authorization or coverage criteria before performing CAN or intra-operative sensor use. Coverage determinations may be influenced by guideline recommendations and evidence summaries.

Check and comply with UnitedHealthcare plan-specific prior authorization requirements
Be aware that guideline discordance (e.g., AAOS recommendation against routine intraoperative navigation in TKA) may affect coverage decisions

Definitions

Appendicular Skeleton System definition

DefinitionAppendicular skeleton system includes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs.

Musculoskeletal System definition

DefinitionMusculoskeletal system is made up of the bones of the skeleton, muscles, cartilage, tendons, ligaments, joints, and other connective tissue that provides form, support, stability, and movement to the body.

Computer-assisted navigation (CAN) — informational definition

DefinitionComputer-assisted navigation (CAN) refers to surgical guidance systems cleared by the U.S. Food and Drug Administration (typically via 510(k)) that provide intraoperative alignment and positioning information to assist orthopedic procedures.

Regulatory noteFDA clearance for CAN devices is commonly via the 510(k) pathway; FDA clearance alone is informational and is not a basis for coverage.

Examples of devices (non‑exhaustive)CTC TCAT TPLAN Surgical System; ExactechGPS; iASSIST Knee System; Intellijoint Navigation System; KneeAlign; Verasense; Stryker Navigation System; NuVasive NVM5/Pulse; JointPoint; OrthAlign Plus.

Intraoperative sensor devices (TKA sensors) — informational definition

DefinitionIntraoperative sensor devices for total knee arthroplasty (TKA) are devices that provide quantitative load/pressure feedback intraoperatively to guide ligament balancing and assess implant stability (examples include VERASENSE systems).

Evidence summarySystematic reviews and RCTs show limited evidence that sensor-guided balancing improves functional outcomes or complication rates compared with manual techniques; further high-quality long-term trials are needed.

Coding/regulatory noteSome sensor systems (e.g., Verasense) are listed among FDA‑cleared devices; FDA clearance is informational and not by itself a basis for coverage determinations.

OpenPayer

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for New Mexico Only)

Coverage Criteria for CAN and Intraoperative Sensors

Coding References

Provider Actions, Billing, and Documentation

Background and Evidence Summary

Definitions

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).

61781	CPT code referenced for cranial and spinal procedures (see cranial/spinal reference).
61782
61783