ModifiedUnitedHealthcarePolicy CS167NJ.G

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

Policy governing use and coverage of computer-assisted surgical navigation (including sensors) for musculoskeletal procedures of the pelvis and appendicular skeleton for UnitedHealthcare New Jersey members.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167NJ.G

Change TypeRevised clinical evidence and references

Effective DateApr 1, 2026

Next Review Date

Key ActionVerify applicable plan and obtain prior authorization when required by the member's benefit plan.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information; archived previous policy version CS167NJ.F.

New Jerseygeographic scope

Pelvis & appendicularanatomic focus

CS167NJ.Gidentifier

Sensor incidentalcoding note

17RCTs (Sheridan 2023)

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Coverage Determinations

Coverage Rationale — Pelvis and Appendicular Skeleton (Not Medically Necessary)

Not medically necessary statement

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 New Jersey members

Coverage Rationale — Intra-operative Sensors (Not Medically Necessary / Incidental)

Not medically necessary statement for sensors

Sensor intraoperative use: 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 separately reimbursable.

Evidence summaries and implications

Evidence highlights and clinical conclusions from systematic reviews, meta-analyses, RCTs, and guideline statements:

CAN outcomes summary: Image-based and imageless computer-assisted navigation (CAN) often improve radiographic alignment metrics compared with conventional techniques, but do not consistently improve short- to mid-term functional outcomes or reduce revision rates; operative times are typically longer with CAN and evidence on complications is insufficient.

Supported by Sheridan et al. (2023), Matar et al. (2020), Hayes review, Panjwani (2019), Lee (2020).

Sensor outcomes summary: Intraoperative sensors improve objective intraoperative balance measurements and increase the proportion of balanced knees intraoperatively, but randomized and comparative data do not show consistent improvement in functional scores, complication rates, or patient satisfaction at short- to mid-term follow-up.

Supported by Tran et al. (2025), Wood et al. (2021), Gustke and case series evidence, Cho (2018).

Evidence gaps and recommendations: Further high-quality, larger, and longer-term randomized trials are needed to determine whether the radiographic or intraoperative measurement advantages of CAN or sensors translate to meaningful patient-oriented outcomes such as function, complication reduction, and revision rates.

Intra‑operative use of an electronic sensor to assess implant stability during total knee arthroplasty is considered incidental to the primary procedure and is not eligible for separate reimbursement. This policy treats sensor deployment during TKA as part of the surgical episode rather than as a billable standalone service.

Use of computer‑assisted navigation (CAN/CAS) for procedures of the upper extremity (e.g., shoulder, elbow) and the axial skeleton (spine) is preliminary; the published literature is limited and does not demonstrate clear improvement in patient‑centered outcomes. Additional controlled studies measuring health outcomes are needed before these indications can be considered medically necessary.

Computer‑assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton, including use of intra‑operative sensors for implant stability during knee arthroplasty, is considered unproven and not medically necessary due to insufficient evidence of efficacy. Available studies show improvements in some radiographic or intraoperative measurements but do not consistently demonstrate improved patient‑centered outcomes or reduced complications that would support coverage.

The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline states 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. Systematic reviews and trials similarly report few differences in clinical and functional outcomes, despite some radiographic improvements with CAN.

Coding and Regulatory Information

Navigational 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 / Device clearancesmixed

FDA 510(k)

Regulatory clearance pathway cited for CAN devices (informational)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Providers should obtain prior authorization for navigational procedure codes when required by the member's plan or state/contractual requirements. Verify eligibility and obtain prior authorization through UnitedHealthcare New Jersey prior authorization processes before scheduling services when applicable.

Prior authorization required when specified by the member's plan, state law, or contract.
Verify benefit coverage and authorization requirements prior to performing navigational procedures for pelvis and appendicular musculoskeletal procedures.

Prior Authorization

Verify Plan and State Authorization Requirements

Prior authorization is required when mandated by the member’s federal, state, or contractual benefit plan. Always check the specific plan and applicable state/contractual requirements; in the event of a conflict, the federal, state, or contractual requirements govern.

Authorization requirements vary by plan and state; do not assume coverage based on this policy alone.
This policy is informational and does not replace plan-specific authorization rules.

Definitions

Appendicular Skeleton System definition

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

Sensor (intra-operative) definition

DefinitionAn electronic device that measures physical properties (e.g., temperature, pressure, distance, speed, torque, acceleration, force, flow) and sends the information to an electronic processor; intraoperative sensors can provide objective assessment of ligament and soft-tissue balancing and postimplantation performance data.

Computer-assisted navigation (CAN) definition

DefinitionAn intraoperative system (image-based or imageless) using data acquisition, registration, and tracking to provide surgeons guidance on component positioning and cutting alignment during orthopedic procedures; devices may be image-based (CT, MRI, fluoroscopy) or imageless and commonly obtain FDA 510(k) clearance.

Background and Context

Computer‑assisted navigation (CAN or CAS) refers to intraoperative systems that assist surgeons with component positioning and cutting alignment during orthopedic procedures. CAN implementations are typically either image‑based (using fluoroscopy, CT, or MRI for data acquisition and registration) or imageless (tracking based on intraoperative landmarks and optical or electromagnetic trackers). The CAN workflow commonly includes data acquisition, registration, and tracking, and newer intraoperative sensors (for example, devices that provide real‑time kinetic or pressure data during total knee arthroplasty) can supply objective measures of ligament and soft‑tissue balance to guide adjustments during the procedure.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167NJ.G

Change TypeRevised clinical evidence and references

Effective DateApr 1, 2026

Next Review Date

Key ActionVerify applicable plan and obtain prior authorization when required by the member's benefit plan.

SourceLink

On This Page

Repeatedly stated across multiple systematic reviews, RCTs, and guideline statements (Sheridan 2023; Matar 2020; Panjwani 2019; Tran 2025).

Note

FDA Clearance Informational

FDA clearance of a surgical navigation device (typically via 510(k)) is informational only and does not by itself establish coverage or medical necessity. Clearance may not require evidence of improved clinical outcomes; coverage decisions rely on clinical evidence of effectiveness for the intended use.

FDA 510(k) clearance is common for navigation systems but does not imply coverage.
Search FDA PMN/510(k) database for device details: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm.

Billing Rule

Applicable Procedure and Diagnosis Codes (Reference)

The following codes are provided for reference only. Inclusion does not imply coverage or separate reimbursement. Codes marked with an asterisk (*) are not on the State of New Jersey Medicaid Fee Schedule and may not be covered by New Jersey Medicaid.

0054T — Computer-assisted musculoskeletal surgical navigational orthopedic procedure, fluoroscopic image-guidance (List separately in addition to code for primary procedure)
0055T — Computer-assisted musculoskeletal surgical navigational orthopedic procedure, CT/MRI image-guidance (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)
Note: 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.

Documentation Required

Policy Use and Documentation

This policy provides guidance for UnitedHealthcare standard benefit plans but does not supersede federal, state, or contractual coverage requirements. Before relying on this policy, check applicable benefit plan documents and legal requirements. UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in benefit administration.

Policy is informational and must be considered alongside plan-specific terms.
In the event of conflict, federal, state, or contractual requirements govern.

Denial Risk

Services Considered Not Medically Necessary

Computer-assisted surgical navigation (CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton, and intra-operative sensor use for implant stability during knee arthroplasty, are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Services described are considered not medically necessary per this policy and may be denied when submitted as separate, payable procedures.
Codes in this policy are intended for navigational procedures for pelvic and appendicular musculoskeletal procedures; for cranial and spinal procedures, see CPT 61781–61783.

Intraoperative sensor (TKA sensors) definition

DefinitionDevices used during total knee arthroplasty that provide real-time kinetic or pressure data (for example, VERASENSE) to quantify soft-tissue balance intraoperatively and guide adjustments to achieve target intercompartmental pressures.

Clinical evidence summaryRandomized trials and systematic reviews show sensors improve intraoperative balance measurements but do not consistently demonstrate improved functional outcomes, complication rates, or patient satisfaction at short- to mid-term follow-up.

Reimbursement noteIntra-operative sensor use for implant stability during TKA is considered incidental to the primary procedure and is not separately reimbursable.