Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty

This policy addresses use of patient‑specific instrumentation (PSI) — e.g., cutting guides and computer‑assisted navigation — for knee arthroplasty (partial or total) in patients with advanced or end‑stage osteoarthritis to improve function and relieve disabling pain. However, PSI is considered experimental/investigational and not covered because evidence does not demonstrate improved long‑term clinical outcomes (only reduced malalignment), and there are concerns about rotational reliability, increased costs and operative time, and applicability is subject to the member’s benefit plan.

"Therapies that are proven effective for the relevant diagnosis or procedure are considered for coverage."

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