CurrentUnitedHealthcarePolicy CS167ID.B

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

This Idaho-only medical policy addresses the use of computer-assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton and the use of intra-operative sensors for implant stability during total knee arthroplasty (TKA), defining the insurer's coverage position and coding/billing clarifications.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167ID.B

Change TypeAdded coding noticeupdated supporting info

Effective DateJun 1, 2026

Next Review Date

Key ActionConsult the Idaho Medicaid Provider Handbook for non-covered and excluded services and note that CPT codes 0054T and 0055T may not be covered by the State of Idaho Medicaid Program.

SourceLink

POLICY UPDATE CHANGES

Added notation that CPT codes 0054T and 0055T are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program.

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

Archived previous policy version CS167ID.A.

1State scope

2Primary disallowed services (CAN, TKA sensors)

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Coverage Summary & Scope

Overview: This Idaho-only policy (Policy Number CS167ID.B, effective June 1, 2026) addresses computer-assisted surgical navigation (CAN/CAS) for musculoskeletal procedures of the pelvis and appendicular skeleton and the use of intra-operative sensors during total knee arthroplasty (TKA).

Scope summary: The policy applies only to the state of Idaho, including Idaho Medicaid Plus plans, and defines the insurer's coverage position and coding/billing clarifications for CAN/CAS and intraoperative sensors. The high-level stance is that these technologies are not covered / unproven and not medically necessary for Idaho due to insufficient evidence of efficacy.

Key policy values

Effective date2026-06-01

Policy numberCS167ID.B

Coverage stanceNot covered (unproven/not medically necessary)

State scopeIdaho-only

Primary disallowed services (CAN, TKA sensors)2

Medical Necessity Determinations

Not Medically Necessary

Policy statements:

Not Medically Necessary 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.
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.

Not Medically Necessary / Unproven Uses

Evidence conclusion: The evidence is insufficient to determine net health outcome benefit; therefore these uses are considered unproven and not medically necessary for Idaho.

Key findings - Hip/THA: Some trials and meta-analyses demonstrate improved component placement accuracy with CAN (e.g., improved acetabular cup placement in select studies) but there is no consistent evidence of improved short-term patient-centered clinical outcomes or complication reduction.

Key findings - Knee/TKA and sensors: Systematic reviews, RCTs, and meta-analyses show that CAN or sensor-guided techniques may improve radiographic alignment or intraoperative soft-tissue balance but generally show no significant improvement in functional scores, complications, or patient-centered outcomes compared with conventional techniques.

RCTs / meta-analyses note: Multiple randomized controlled trials, systematic reviews, and meta-analyses (published 2019–2025 and cited herein) were evaluated; while some report improved radiographic precision, overall clinical benefit on health outcomes is not established and evidence is inconsistent, supporting the policy conclusion that these uses are unproven and not medically necessary in Idaho.

Coding Reference

Referenced navigation/add-on CPT codes (listed for reference; inclusion does not imply coverage)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).

CPT Category III codes noted as potentially not covered on Idaho Medicaid fee scheduleCPT

0054T	Category III CPT code referenced; notation added that 0054T is not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid
0055T	Category III CPT code referenced; notation added that 0055T is not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid

Listing of a procedure code in this policy does not imply coverage or guarantee reimbursement. CPT codes 0054T and 0055T are Category III codes noted in this policy and are not on the State of Idaho Medicaid Fee Schedule, and therefore may not be covered by the State of Idaho Medicaid Program; providers should consult the Idaho Medicaid Provider Handbook for non-covered and excluded services.

Provider Actions & Billing Rules

Billing Rule

Intra-operative sensor 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.

27599
20985
0054T
0055T

Billing Rule

Idaho Medicaid fee schedule limitation

CPT codes 0054T and 0055T are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program. Providers should consult the Idaho Medicaid Provider Handbook for information on non-covered and excluded services.

0054T

Background & Definitions

Background: Computer-assisted navigation (CAN/CAS) refers to image-based or imageless computer-enabled tracking systems used to aid implant positioning, alignment, and verification of intended implant placement in musculoskeletal surgery (including fracture fixation, ligament reconstruction, osteotomy, tumor resection, and preparation for joint arthroplasty).

Sensors: Sensors are electronic devices that measure physical properties and can provide intraoperative kinetic data for ligament and soft-tissue balancing and postimplantation monitoring. While some studies show improved radiographic alignment or more precise component placement with CAN or sensor assistance, the evidence is inconsistent or lacking for improved patient-centered clinical outcomes; the impact on net health outcomes is therefore unclear.

Definitions:

Appendicular Skeleton System: Includes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs.

Musculoskeletal System: The anatomical system made up of bones, muscles, cartilage, tendons, ligaments, joints, and other connective tissue that support and bind tissues and organs together.

Sensor: An electronic device that measures physical properties (e.g., temperature, pressure, force) and transmits data to an electronic processor; in this context, used intraoperatively for ligament and soft tissue balancing in TKA and for postimplantation monitoring.

Evidence Summary

Evidence summary

Overall evidence conclusionInsufficient to determine net health outcome benefit; therefore unproven and not medically necessary for Idaho.

Key findings - Hip/THASome trials show improved component placement accuracy but no consistent short-term clinical outcome or complication benefit.

Key findings - Knee/TKA sensorsSystematic reviews and RCTs show no significant improvement in functional scores or complications for sensor-guided balancing vs manual techniques.

Randomized controlled trials and meta-analyses citedMultiple RCTs, systematic reviews, and meta-analyses (2020-2025) comparing navigation/robotic/sensor-guided techniques to conventional arthroplasty in orthopedic journals.

Revision History

2026-06-01material_changeLatest

Added notation that CPT codes 0054T and 0055T are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program; guidance directs providers to refer to the Idaho Medicaid Provider Handbook for non-covered and excluded services.

2026-06-01updated_supporting_information

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

2026-06-01