ModifiedUnitedHealthcarePolicy CS167TN.H

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

This policy governs use of computer-assisted surgical navigation (CAN/CAS) and intra-operative sensors for musculoskeletal procedures (pelvis and appendicular skeleton) for Tennessee Medicaid and CoverKids members.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167TN.H

Change TypeRevised clinical evidence and supporting sectionsarchived prior version

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionVerify prior authorization requirements per UnitedHealthcare plan and applicable state/federal contractual requirements before proceeding.

SourceLink

POLICY UPDATE CHANGES

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

Not medically necessaryCoverage stance for CAN (pelvis & appendicular)

TN Medicaid & CoverKidsPopulation governed

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

50 RCTsRCTs in major review

47,675

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Total patients summarized

Coverage Determinations

Not medically necessary — CAN and intra-operative sensors

Covered when ALL of the following are met

Pelvis and Appendicular Skeleton CAN: 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.

See supporting evidence summaries for hip/pelvis (chunks 9) and knee (chunks 15).

Intra-operative sensors for TKA: 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.

Sensor use is considered incidental to the primary procedure and not separately reimbursable; see TKA sensor evidence summaries (chunks 24, 26).

Coverage stance for CAN and intraoperative sensors

Summary of evidence-based coverage considerations

Evidence summary: CAN and intraoperative sensors improve certain technical or radiographic measures (implant alignment, placement accuracy, intraoperative balance) but high-quality randomized trials and meta-analyses generally do not show consistent improvements in patient-reported outcomes, function, complication rates, or long-term benefits.

Supported by multiple systematic reviews, meta-analyses, device-specific assessments, and AAOS guideline (chunks 18, 19, 20, 21, 24, 26).

Intra-operative use of a sensor during knee replacement arthroplasty is considered incidental to the primary procedure and is not eligible for separate reimbursement. The policy’s coding clarifications identify sensors as examples of unlisted procedures billed under codes such as 27599 while navigational add-on codes include 0054T, 0055T, and 20985 which are intended to be listed in addition to the primary procedure code.

Current evidence for computer-assisted navigation (CAN/CAS) and intraoperative sensors in the upper extremity and axial skeleton is preliminary or insufficient. Systematic reviews and meta-analyses specific to total knee arthroplasty (TKA) and targeted studies in other sites do not demonstrate consistent improvements in patient-centered outcomes, and controlled studies measuring longer-term health outcomes are lacking. Clinical practice guidance for the knee (AAOS) also does not support routine intraoperative navigation in TKA because it has not shown outcome or complication benefits.

Computer-assisted surgical navigation for musculoskeletal procedures of the pelvis and appendicular skeleton is considered unproven and therefore not medically necessary due to insufficient evidence of efficacy. Although CAN may improve technical precision (for example, bone cuts or implant alignment), the available literature does not establish consistent clinical benefit for these anatomical regions, and additional controlled studies measuring meaningful patient outcomes are required.

The use of an intra-operative sensor to assess implant stability during knee replacement arthroplasty and to improve postoperative knee function is considered unproven and not medically necessary. High-quality randomized trials and meta-analyses have not shown significant improvements in functional scores, complication rates, or range of motion with sensor-guided balancing compared to manual techniques, and sensor use is treated as incidental to the primary procedure for reimbursement purposes.

Routine use of intraoperative navigation in total knee arthroplasty and routine use of intraoperative sensors to improve postoperative clinical outcomes are not supported by consistent evidence of benefit. The American Academy of Orthopaedic Surgeons (AAOS) guidelines report no difference in outcomes or complications with intraoperative navigation in TKA, and pooled trial evidence for sensors similarly fails to show meaningful functional or complication advantages; therefore routine, unselected use may be considered not medically necessary when no patient-specific rationale or demonstrated benefit is provided.

Procedure and Device Coding

Navigation and sensor 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).

FDA-cleared CAN and sensor devices (informational)mixed

Device list

CTC TCAT, TPLAN Surgical System, Robodoc Encore, ExactechGPS, iASSIST, Intellijoint, JointPoint, KneeAlign, NuVasive NVM5/Pulse, OrthAlign, Stryker systems, Verasense/VeraSense, Vital Navigation

Provider Billing, Documentation, and Authorization

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for certain computer-assisted navigation (CAN) procedures or devices. Providers should verify benefit coverage and obtain any required prior authorization from UnitedHealthcare before scheduling services.

Verify member benefits and prior authorization requirements prior to service.
Contact UnitedHealthcare provider relations or use the payer portal for authorization submission.

Denial Risk

Denial Risk for CAN and Intra-operative Sensors

Intra-operative sensors used for implant stability during knee replacement arthroplasty (e.g., Verasense, other sensor systems) and CAN for pelvic/appendicular musculoskeletal procedures carry a risk of claim denial when billed separately. Intra-operative sensor use is considered incidental to the primary procedure and is not eligible for separate reimbursement per this policy.

Key Terms and Device Examples

CAN/CAS definition — computer-assisted surgical navigation

DefinitionComputer-assisted surgical navigation (CAN), also known as computer-assisted surgery (CAS), describes the use of computer-enabled tracking systems to facilitate alignment and guide implant placement in musculoskeletal procedures (image-based or imageless systems).

Key functionsTypical CAN workflow includes data acquisition (fluoroscopy, CT, MRI, or imageless), registration of images to patient anatomy, and real-time tracking of tools relative to bone anatomy.

Common applicationsUsed for fracture fixation, ligament reconstruction, osteotomy, tumor resection, preparation for joint arthroplasty (TKA and THA), and verification of implant placement.

Sensor — intraoperative electronic device definition

DefinitionA sensor is an electronic device that measures physical properties (e.g., temperature, pressure, distance, speed, torque, acceleration, force) and transmits that information to an electronic processor for intraoperative or postoperative use.

Clinical and Technical Background

Computer-assisted navigation (CAN), also called computer-assisted surgery (CAS), uses image-based (CT, MRI, fluoroscopy) or imageless tracking and registration systems to provide intraoperative guidance for bone cuts and implant positioning. CAN systems aim to improve surgical accuracy and prosthetic alignment, while sensors are electronic devices used intraoperatively to quantify compartmental loading or ligament balance (for example, during total knee arthroplasty) and may also record post-implantation performance metrics. Although these technologies can improve technical measures such as alignment or intraoperative balance, evidence linking improved precision to consistent, meaningful patient-centered outcomes (function, pain, complications, or long-term benefit) is currently inconsistent or lacking.

Policy Change Log

2026-04-01revisionLatest

Updated Description of Services, Clinical Evidence, and References sections; archived previous policy version CS167TN.G.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS167TN.H

Change TypeRevised clinical evidence and supporting sectionsarchived prior version

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionVerify prior authorization requirements per UnitedHealthcare plan and applicable state/federal contractual requirements before proceeding.

SourceLink

On This Page

Separate billing for intra-operative sensors (e.g., unlisted code 27599 examples) may be denied.
CAN codes (0054T, 0055T, 20985) may be denied when not meeting policy criteria or when billed inappropriately.

Denial Risk

Guideline-based Risk

AAOS clinical practice guidelines state there is strong evidence to support not using intraoperative navigation in total knee arthroplasty (TKA) because outcomes and complications do not differ; this guideline-based evidence supports potential denial of CAN and related intra-operative sensor claims when submitted for TKA without compelling supporting evidence.

AAOS guideline: strong evidence against routine intraoperative navigation in TKA.
Payers may deny claims that conflict with current guideline-based recommendations absent supporting clinical justification.

Documentation Required

Device Clearance Documentation

When submitting claims or authorization requests that reference a specific navigation system or sensor, include device clearance documentation such as the FDA 510(k) number or device name and model. Note that FDA 510(k) clearance is informational and does not by itself establish medical necessity or coverage.

Provide FDA 510(k) clearance number or searchable device name (e.g., ExactechGPS, Verasense Knee System) when available.
Include manufacturer's documentation and clinical justification if relying on device-specific claims.

Note

Not Specified in This Document

This section does not specify additional provider actions beyond those listed above. For items not detailed in this document, providers should verify contract terms, medical policy specifics, and member benefits with UnitedHealthcare.

If a required action is not specified here, contact UnitedHealthcare for clarification.
Maintain complete operative and device documentation to support any request for coverage review.

Intraoperative use in TKASmart sensors can provide objective assessment of ligament and soft-tissue balancing during total knee arthroplasty and can supply postimplantation data to monitor implant performance and patient recovery.

Measured parametersSensors may quantify force, pressure, intercompartmental load, and other kinematic metrics to guide balancing and surgical adjustments.

Appendicular Skeleton System definition

DefinitionAppendicular Skeleton System includes the bones of the shoulder girdle, the upper limbs, pelvic girdle, and the lower limbs (Anderson et al., 2022).

ScopeEncompasses both upper and lower extremity skeletal structures and their girdles relevant to musculoskeletal surgical procedures.

ContrastDistinct from the axial skeleton, which includes the skull, vertebral column, and thoracic cage.

Computer-assisted navigation (CAN) — example systems listed

Example systems (informational)ExactechGPS; KneeAlign; iASSIST Knee System; Intellijoint Navigation System; JointPoint; OrthAlign; Stryker Navigation System (including OrthoMap/Spinemap); NuVasive NVM5/Pulse; Digimatch/Robodoc Encore; CTC TCAT/ TPLAN Surgical System.

Typical clearance pathwayMost CAN devices are FDA-cleared via the 510(k) process and are treated as surgical information systems by the FDA.

Primary clinical roleProvide intraoperative guidance for bone cuts, implant positioning, and alignment through image-based or imageless tracking and registration.

Intraoperative sensors (TKA sensors) — example devices like VERASENSE

Example devicesVerasense / VeraSense (Verasense Knee System; Verasense for Zimmer Biomet Persona) — sensor systems used to quantify compartmental loading during TKA.

Other sensor mentionsOrthosensor (reported in case series) and device outputs used to guide additional soft-tissue releases and balancing corrections intraoperatively.

Clinical roleThese intraoperative sensors quantify medial and lateral compartment pressures or intercompartmental load to inform ligament balancing decisions during total knee arthroplasty.