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CPT 20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-lessLast reviewed at VbBS in August 2018. Minutes indicate that the staff recommendation was accepted without significant discussion. HERC approved the recommendations without change. EvidenceKnee ligament repairEggerding 2014, Cochrane review of computer assisted ACL or PCL reconstruction () N=5 RCTs with 366 participants, all ACL repairmoderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favoring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/ 87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.Authors’ conclusions From the available evidence, we are unable to demonstrate or refute a favorable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. Total knee arthroplastyBurnett 2013, systematic review of computer assisted TKA vs conventional surgery () N=19 RCTs (2180 patients)Follow up ranged from immediately postoperative to 5 years. Most were 2-3 monthsCoronal plane alignment is improved with navigated TKA with fewer radiographic outliers. We found limited evidence of improvements in any other variable, and function was not improved. The duration of surgery is increased and there are unique complications related to navigated TKA. The long-term benefits of additional increase in accuracy of alignment are not supported by any current evidence.Conclusions: There are few short and medium- and no long-term studies demonstrating improved clinical outcomes using navigated TKA. Longer-term studies demonstrating improved function, lower revision rates, and acceptable costs are required before navigated TKA may be widely adopted. Dyrhovden 2016: 8 year follow up of computer assisted (CAN) vs conventional (CON) TKACAS, N=3,665. CON, N=20,019Norwegian Arthroplasty Registry studyProsthesis survival and risk of revision were similar for CAS and CON. CAS had significantly fewer revisions due to malalignment. Otherwise, no statistically significant difference was found between the groups in analyses of secondary outcomes.Mean operating time was 13 minutes longer in CAS.Interpretation: At 8 years of follow-up, CAS and CON had similar rates of overall revision, but CAS had fewer revisions due to malalignment. Total hip replacementNote: no newer systematic review or meta-analysis was found Gandhi 2009, meta-analysis of computer-aided total hip replacementN=3 studies (250 patients)The beneficial odds ratio for the number of outliers was 0.285 (95% confidence interval [CI]: 0.143 to 0.569; p<0.001). We conclude that navigation in hip arthroplasty improves the precision of acetabular cup placement by decreasing the number of outliers from the desired alignment.Other payer policies:MODA 2017Considers computer assisted musculoskeletal procedures to be experimentalWellmark BCBS 2017Considers computer assisted musculoskeletal procedures to be experimentalHERC staff summary: Computer-assisted navigation for orthopedic joint surgeries appears to result in improved placement of prosthetic immediately after surgery, but there is no difference in long-term need for revision or in functional outcomes compared to conventional surgery. There is a longer operative time reported for these procedures compared to conventional surgery. It currently does not appear to be standard of care, as it is considered experimental by the commercial payers surveyed.HERC staff recommendations:Place CPT 20985 (Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less) on line 660 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITSAdvise HSD to remove CPT 20985 from the Ancillary listAdd the following entry to GN173GUIDELINE NOTE 173, INTERVENTIONS THAT ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS FOR CERTAIN CONDITIONS660The following Interventions are prioritized on Line 660 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS:Procedure CodeIntervention DescriptionRationaleLast Review20985Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-lessInsufficient evidence of effectivenessAugust 2018 ................
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