Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Commercial Medical Policy

COVERAGE RATIONALE

Computer-assisted surgical navigation for musculoskeletal procedures is unproven and not medically necessary due to insufficient evidence of efficacy.

The use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty is unproven and not medically necessary due to insufficient evidence of efficacy.

APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.

Coding Clarification: Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.

CPT Code

Description

 

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)

0396T

Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (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)

CPT® is a registered trademark of the American Medical Association

DESCRIPTION OF SERVICES                                                                                                                                                                            

Computer-assisted navigation (CAN) in musculoskeletal procedures describes the use of computer-enabled tracking systems to facilitate alignment in a variety of surgical procedures, including fixation of fractures, ligament reconstruction, osteotomy, tumor resection, preparation of the bone for joint arthroplasty (knee and hip), and verification of intended implant placement. The goal of CAN in musculoskeletal procedures is to increase surgical accuracy and reduce the chance of malposition.

CAN may be image based or non-image based. Image based devices use preoperative computed tomography (CT) scans and operative fluoroscopy to direct implant positioning. Newer non-image based devices use information obtained in the operating room, typically with infrared probes.

CAN involves 3 steps described below:

  • Data Acquisition: Data can be acquired via fluoroscopic, CT or magnetic resonance imaging (MRI) guided, or imageless systems. This data is then used for registration and tracking.
  • Registration: Registration refers to the ability of relating images (i.e., x-rays, CT, MRI or patient’s 3-D anatomy) to the anatomical position in the surgical field. Registration techniques may require the placement of pins or “fiduciary markers” in the target bone. A surface-matching technique can be used in which the shapes of the bone surface model generated from preoperative images are matched to surface data points collected during surgery.
  • Tracking: Tracking refers to the sensors and measurement devices that can provide feedback during surgery regarding the orientation and relative position of tools to bone anatomy. For example, optical or electromagnetic trackers can be attached to regular surgical tools, which can then provide real time information of the position and orientation of the tools’ alignment with respect to the bony anatomy of interest (Swank and Lehnert, 2005).

Policy Codes

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* computer-assisted-surg-nav-musculoskeletal-procs.pdf
Click to Download: COMPUTER-ASSISTED SURGICAL NAVIGATION FOR MUSCULOSKELETAL PROCEDURES

INSTRUCTIONS FOR USE

This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Medical Policy is provided for informational purposes. It does not constitute medical advice.

This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5).

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. UnitedHealthcare Medical Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.