Clinical Policy Title: Robotic Assisted Surgery
Clinical Policy Number: 18.03.01
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
March 1, 2014
September 18, 2013
September 21, 2016
September 2017
Policy contains:
 Robotic assisted surgery.
 DaVinci surgical system.
 ZEUS robotic system.
Related Policies:
CP# 12.03.04 - Radiofrequency (RF) Ablation of Uterine Fibroids
ABOUT THIS POLICY: Keystone First has developed clinical policies to assist with making coverage determinations. Keystone First’s clinical policies
are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies,
the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies
along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific
definition of “medically necessary,” and the specific facts of the particular situation are considered by Keystone First when making coverage
determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements,
the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Keystone First’s clinical policies are for informational
purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the
treatment decisions for their patients. Keystone First’s clinical policies are reflective of evidence-based medicine at the time of review. As medical
science evolves, Keystone First will update its clinical policies as necessary. Keystone First’s clinical policies are not guarantees of payment
Coverage Policy
Keystone First considers the use of robotic assistance in surgery to be investigational and, therefore, not
medically necessary.
Limitations:
Robotic assistance is not separately reimbursable from the primary surgical procedure.
Alternative Covered Services:
Surgeon consultation for approved standard or minimally invasive surgery without the assistance of robotic
technology.
Background
1
Robotic assisted surgery has become increasingly common in the United States and in the world, rising from
80,000 to 500,000 procedures between 2007 and 2013. The new technology has rapidly expanded. In
2010, 9.5% of hysterectomies in U.S. hospitals were performed using robotic technology, up from just 0.5%
three years earlier. In hospitals that introduced robotic surgery for hysterectomy, 22.4% of the procedures
were performed using a robot three years lager (Wright, 2013).
The use of computer assistance allows the surgeon to take advantage of the miniaturization possible that
leads to smaller incisions, less pain and somewhat reduced hospitalization time. The robotic assistance
devices allow the surgeon to operate from a console with three dimensional viewing. Computer technology
translates surgeons’ hand motions into precise manipulation of surgical instruments inserted into the
patients’ bodies through cannulas. This allows the surgeon to operate remotely. Much of the original work
on robot assisted surgery was performed through grants by the U.S. military looking for ways to operate
remotely on soldiers injured on the battlefield. The greatest use of robotics occurs within hospitals where
the surgeon is in close proximity to the patient but taking advantage of miniaturization of the incision.
Perhaps the most commonly used model of robotic assisted surgery is the daVinci® system, made by
Intuitive Surgical. It is often used for prostatectomies, hysterectomies, bypass surgeries, and removing
cancerous tissue (Carlson, 2016). The U.S. Food and Drug Administration approved the device in 2000.
Another common model is the ZEUS Robotic Surgical System (also owned by Intuitive Surgical).
The Consensus document from the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES)
lists four elements of advantages for robotic surgeries (Herron, 2008):
 Superior visualization, including 3-dimensional imaging of the operative field.
 Stabilization of instruments within the surgical field.
 Mechanical advantages over traditional laparoscopy.
 Improved ergonomics for the operating surgeon.
SAGES further indicates the optimal use of robotics for intra-abdominal surgery is where the procedure is in
a defined space within the abdomen and in which fine dissection and micro-suturing is needed.
The application of robotic assisted surgery is now found in the following fields. The majority of these
procedures are performed without the use of such computer assistance:
Specialty
Cardiology
Procedures


Ablation of aberrant conduction systems.
Interventional cardiac procedures.

3-D cardiac mapping.
Cardiothoracic
surgery


Atrial septal defect closure.
Endoscopic coronary artery bypass.


MIDCAB.
Valve repair or replacement.
General surgery




Bariatric surgery.
Cholecystectomy.
Colectomy.
Gastrectomy.




Incisional hernia repair.
Nissan fundoplication.
Pancreatectomy.
Rectopexy.
1

Heller myotomy.

Splenectomy.
Gynecology



Hysterectomy.
Myomectomy.
Sacrocolpopexy.



Staging for cancer.
Tubal anastomosis.
Vesicovaginal fistula repair.
Orthopedic surgery

Total hip replacement.

Total knee replacement.
Pediatric surgery




Anal pull-through for imperforate anus.
Appendectomy.
Cholecystectomy.
Fundoplication.




Gastric banding.
Heminephrectomy.
Pyeloplasty.
Vascular ring repair.
Thoracic surgery


Lobectomy.
Thymectomy.

Transthoracic.
esophagectomy.
Urology



Cystectomy.
Donor nephrectomy.
Partial/radical nephrectomy.


Pyeloplasty.
Radical prostatectomy.
The large number of procedures for which robotic assistance has been used further indicates the
technology is in its infancy, with efforts to find optimal outcomes for patients. Most of the above listed
procedures have been performed a small number of times and have not been subjected to randomized
controlled clinical trials.
Methods
Searches
Keystone First searched PubMed and the databases of:
 UK National Health Services Centre for Reviews and Dissemination.
 Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
 The Centers for Medicare & Medicaid Services.
We conducted searches on August 18, 2016. Search terms were “robotic systems”, “robotic assisted
surgery,” and “da Vinci surgery.”
We included:
 Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a scientific
endeavor, and are thus rated highest in evidence-grading hierarchies.
 Guidelines based on systematic reviews.
 Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost
studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which
also rank near the top of evidence hierarchies.
Findings
2
Researchers have assessed a variety of outcomes of robotically-assisted surgery. Those measures (typically
in studies comparing robotic surgery to laparoscopic surgery) include length of stay, blood loss, anesthesia
required, recovery time, time in the operating room, complications, and costs.
Because many procedures using robotic technology having been performed, the literature contains a large
number of controlled trials (along with meta-analyses and systematic reviews). While some researchers
conclude that robotic surgery is superior to traditional laparotomy or laparoscopy, a number of others
strongly believe that the superiority of robotic surgery is unproven.
On March 14, 2013, American College of Obstetrics and Gynecology (ACOG) president James T. Breeden
MD issued a statement on the College’s web site. Breeden stated that “studies have shown that adding this
expensive technology for routine surgical care does not improve patient outcomes. . . there is no good data
proving that robotic hysterectomy is even as good as – let alone better – than existing, and far less costly,
minimally invasive alternatives.” Breeden cited “aggressive direct-to-consumer marketing of the latest
medical technologies may mislead the public into believing that they are the best choice.”
In March 2016, Project Hope Senior Fellow and former Health Care Financing Administration director Gail
Wilensky PhD published a peer-reviewed journal article echoing these conclusions. Evidence of effective
outcomes of robotic surgery patients compared to laparoscopy patients is “considerably less compelling,”
she wrote. Wilensky also focused on the cost of robotic surgery. The purchase price of a single machine is
around $2 million, and thus the average incremental cost of robotic surgery compared to laparoscopy is
about $3,000 to $6,000 per patient. She did acknowledge that the greatest efficacy has been found in
those procedures that are most difficult to reach with a laparoscope, such as prostatectomy and some head
and neck surgeries; but concluded that “there is no indication that these robotic procedures are likely to
become more cost-effective over time” (Wilensky, 2016).
Both Breeden and Wilensky cited a large 2013 JAMA study published by Columbia University researchers
covering 264,758 women undergoing hysterectomy in 441 hospitals between 2007 and 2010. The study
found similar rates of complications, long lengths of stay, transfusions, and nursing home discharges for the
two groups, but also cited concern over the higher average costs associated with robotic surgery, especially
as the percent of hysterectomies performed with a robot soared (Wrignt, 2013).
Meta-analyses and systematic reviews have failed to establish a pattern of improved long-term efficacy of
this procedure. In addition to the seminal Columbia research, the following were published in the first half
of 2016:

A meta-analysis by researchers at the Geisel School of Medicine at Dartmouth College found no
difference in complications, length of stay, operating time, conversions to laparotomy, and blood
loss between robotic vs. laparoscopic hysterectomies, leading to the conclusion that robotic
surgery’s role in benign gynecological surgery “remains unclear” (Albright, 2016).
3

In patients affected by sleep apnea undergoing tongue reduction, failure rates of trans-oral robotic
surgery and coblation tongue surgery were not significantly different (34.4% and 38.5%). However,
complication rates were significantly higher in the robotic group (21.3% vs. 8.4%) (Camaroto, 2016).

A large Meta-analysis (99 articles, 14,448 patients) comparing outcomes for robotic vs. minimally
invasive surgery for various types of procedures documented robotic groups had reduced blood
loss, and a lower transfusion rate. However, robotic groups had similar LOS and 30 day
complication rates, and a higher average operative time. The report noted that many studies
suffered from high risk of bias and inadequate statistical power (Tan, 2016).

A meta-analysis of sacrocolpopexy (treating prolapse of the apical segment of the vagina)
compared results for patients undergoing laparoscopy vs. open surgery vs. robotic. In 9 studies of
1157 subjects, no difference was found in anatomical outcomes, mortality, LOS, and post-operative
quality of life, but the robotic subjects experienced higher post-op pain and longer operating times
(DeBouveia, 2016).

In a review of 24 studies on radical prostatectomy (laparoscopy vs. robotic), the robotic subjects
had less blood loss and a lower transfusion rate, along with better functional outcomes – but there
was no difference in perioperative and oncological outcomes (Huang, 2016).

An analysis of 18 studies of 4878 patients undergoing thyroidectomy, comparing the conventional
(open) approach vs. endoscopic vs. robotic documented a similar risk of post-operative
complications, but a longer operative time (mean difference 43.5 minutes) for robotic-assisted
surgery procedures than conventional surgery (Kandil, 2016).
Some articles have analyzed additional costs for treating patients with robotic assisted surgery. As
mentioned, average incremental costs per procedure are estimated at $3,000 to $6,000 (Wilensky, 2016).
Trials of sacrocolpopexy, in addition to finding robotic procedures had longer time in the operating room
and caused more pain than laparoscopic surgery, calculated that average cost per patients was nearly twice
as high for robotic surgery when cost of purchase and maintenance was factored in, i.e. $19,616 vs.
$11,573 (Callewaert, 2016). A study of 10,347 U.S. women diagnosed with uterine cancer from who
underwent hysterectomies from 2008-2012 found that robotic surgery had higher median charges than
laparoscopic surgery, i.e. $38,161 vs. $31,476 (Zakhari, 2015).
Policy Updates:
Ten (10) new peer-reviewed references have been added to this policy, eight (8) of which were published in
2016. Of these three (3) have been added to the Summary of Clinical Evidence section. There are also an
additional three (3) references added to the Clinical Guidelines/Other section, two (2) of which were
published in 2016.
The Findings section has been expanded. Discussion of the 2013 statement by ACOG President James T.
Breeden MD that concluded robotic surgery doesn’t improve patient outcomes has been included, as did
the 2016 journal article by Gail Wilensky PhD, which also presented analysis of incremental costs of using
4
robotic surgery instead of laparoscopic surgery. A summary of a seminal article in JAMA covering over
264,000 women undergoing hysterectomy, plus recent meta analyses and cost analyses of robotic surgery
are now included in the policy.
Summary of Clinical Evidence
Citation
Content, Methods, Recommendations
Albright (2016)
Key Points:
Complications in
hysterectomy,
laparoscopic vs.
robotic



41 complications among 326 patients
No significant differences in rates of class 1-2-3-4 complications
No significant differences in mean length of stay, operating time, conversions to
laparotomy, or blood loss
Concludes the role of robotic surgery in benign gynecology “remains unclear”
Tan (2016)
Outcomes, robotic vs.
minimally invasive
surgery
Key Points:




99 studies, 14,448 subjects, variety of procedures
Robotic subjects had less blood loss, lower transfusion rate
Robotic subjects had similar LOS and 30 day complication rates
Robotic subjects had longer operative time
Many studies had high risk of bias or inadequate statistical power
Fonseka (2015)
Comparing methods of
cystectomy
Lang (2015)
Thyroidectomy via
robotic and nonrobotic assisted
methods
Cundy (2014)
Pyeloplasty in children
Robertson (2013)
Treatment of localized
prostate cancer
Key Points:




24 studies, 2104 cases
Robot assisted vs laparoscopic vs. open cystectomy
Robot assisted had outcomes superior to open
Robot = longer operative time vs. laparoscopic, same LOS, blood loss, complications
Key Points:



10 studies, 2205 cases (differentiated thyroid carcinoma)
Open vs. robotic-assisted thyroidectomy
Robotic resulted in fewer central lymph nodes, less-complete thyroid resections,
otherwise similar outcomes
Key Points:




12 studies, 679 participants
Open vs. laparoscopic vs. robotic-assisted pyeloplasty
Robotic had shorter LOS, lower anesthesia required, lower blood loss
Robotic had higher cost, longer operating time
Key Points:


Meta-analysis of 58 studies (only 1 RCT) of 19,064 men with prostate surgery
Fewer significant complications with robotic (0.4%) vs. laparoscopic (2.9%)
5
Close (2013)
Treatment of localized
prostate cancer
Wright (2013)
Benign gynecology
surgery
 Lower incidence residual tumor invading margins of resected tissue by robot.
Key Points:


Meta-analysis of patients with prostate cancer for up to 10 years.
Higher cost of robotic prostatectomy may be offset by lower risk of early harms and
positive margin, if > 150 cases are performed each year.”
Key Points:


441 U.S. hospitals, 264,758 procedures, 2007-2010, robotic vs. laparoscopic
Similar rates of complications, LOS > 2 days, transfusions, discharge to nursing home
Average additional costs of robotic patients was $2189
Glossary
da Vinci robotic surgical system — A device featuring a magnified 3D high definition vision system and tiny
instruments that bend and rotate. Surgeons operate remotely in a console, using several small incisions.
Laparoscopic surgery — Surgery that utilizes a laparoscope with a video camera and surgical instruments
inserted through small incisions. (Gale Encyclopedia of Medicine. ©2008 The Gale Group, Inc).
Minimally invasive surgery — Surgery done with only a small incision or no incision at all, such as through a
cannula with a laparoscope or endoscope (Dorland's Medical Dictionary for Health Consumers).
Robotic assisted surgeries — The performance of operative procedures with the assistance of robotic
technology. It allows great precision and is used for remote-control, minimally invasive procedures. Current
systems consist of computer-controlled electromechanical devices that work in response to controls
manipulated by the surgeon.
ZEUS robotic surgical system — A medical robot used in minimally assisted surgery, using three arms
(voice-activated endoscope, and two to mimic the surgeon’s movements for incisions and extractions).
References
Professional society guidelines/other:
American Association of Gynecologic Laparoscopists. Guidelines for privileging for robotic-assisted
gynecologic laparoscopy. J Min Invasive Gynecol. 2014;21(2):157 – 67.
American College of Obstetrics and Gynecology. Committee opinion no. 628: robotic surgery in gynecology.
Obstet Gynecol. 2015;125(3):760 – 67.
Breeden JT. Statement on robotic surgery. American College of Obstetrics and Gynecology, March 14,
2013. http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-RoboticSurgery. Accessed August 19, 2016.
Carlson A. Trends in medical robots & robotic surgery companies. Kaleidoscope. April 5, 2016.
http://kascope.com/trends-in-medical-robots-robotic-surgery-companies/. Accessed August 18, 2016.
6
Herron DM, Marohn M; SAGES-MIRA Robotic Surgery Consensus Group. A consensus document on robotic
surgery. Surg Endosc. 2008;22(2):313 – 25.
Milowsky MI, Rumble RB, Booth CM, et al. Guideline on muscle-invasive and metastatic bladder cancer
(European Association of Urology Guideline): American Society of Clinical Oncology Clinical Practice
Guideline Endorsement. J Clin Oncol. 2016;1;34(16):1945 – 52.
Stenzl A, Cowan NC, De Santis M, et al. The updated EAU guidelines on muscle-invasive and metastatic
bladder cancer. Eur Urol. 2009;55(4):815 – 25.
U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health. ZEUS® Robotic
Surgical System. 501(k) Premarket Notification. October 5, 2001.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K003431. Accessed August 18,
2016.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Intuitive Surgical® da
Vinci. 501(k) Premarket Notification. December 16, 2009.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K090993. Accessed August 18,
2016.
Peer-reviewed references
Albright BB, Witte T, Tofte AN, et al. Robotic versus laparoscopic hysterectomy for benign disease: A
systematic review and meta-analysis of randomized trials. J Minim Invasive Gynecol. 2016;23(1):18 – 27.
Callewaert G, Bosteels J, Housmans S, et al. Laparoscopic versus robotic-assisted sacrocolpopexy for pelvic
organ prolapse: a systematic review. Gyecol Surg. 2016;13:115 – 23.
Cammaroto G, Montevecchi F, D’Agostino G, et al. Tongue reduction for OSAHS: TORSs vs coblations,
technologies vs techniques, apples vs oranges. Eur Arch Otorhinolaryngol. May 24, 2016 (Epub ahead of
print).
Close A, Robertson C, Rushton S, et al. Comparative cost-effectiveness of robot-assisted and standard
laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of men with
localised prostate cancer: A health technology assessment from the perspective of the UK National Health
Service. Eur Urol. 2013;64(3):361 – 69.
Cundy TP, Harling L, Hughes-Hallett A et al. Meta-analysis of robot-assisted vs. conventional laparoscopic
and open pyeloplasty in children. BJU Int. 2014;114(4):582 – 94.
DeGouveia De Sa M, Claydon LS, Whitlow B, Dolcet Artahona MA. Robotic versus laparoscopic
sacrocolpopexy for treatment of prolapse of the apical segment of the vagina: a systematic review and
meta-analysis. Int J Urogynecol J. 2016;27(3):355 – 66.
Fonseka T, Ahmed K, Froghi S. Comparing robotic, laparoscopic, and open cystectomy: A systemic review
and meta-analysis. Arch Ital Urol Adrol. 2015;87(1):41 – 48.
Hazey JW, Melvin WS. Robot-assisted general surgery. Semin Laparosc Surg. 2004;11(2):107 – 12.
7
Huang X, Wang L, Zheng X, Wang X. Comparison of perioperative, functional, and oncologic outcomes
between standard laparoscopic and robotic-assisted radical prostatectomy: a systemic review and metaanalysis. Surg Endosc. July 21, 2016 (Epub ahead of print)
Jackson NR, Yao L, Tufano RP, Kandil EH. Safety of robotic thyroidectomy approaches: Meta-analysis and
systematic review. Head Neck. 2014;36(1):137 – 43.
Kandil E, Hammad AY, Walvekar RR, et al. Robotic thyroidectomy versus nonrobotic approaches: A metaanalysis examining surgical outcomes. Surg Innov. 2016;23(3):317 – 25.
Klatte T, Shariat SF, Remzi M. Systematic review and meta-analysis of perioperative and oncologic
outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small
renal tumors. J Urol. 2014;19(5):1209 – 17.
Lang BH, Wong CK, Tsang JS, Wong KP, Wan WY. A systemic review and meta-analysis in evaluating
completeness and outcomes of robotic thyroidectomy. Laryngoscope. 2015;125(2):509 – 18.
Liao G, Zhao Z, Lin S et al. Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four
randomized controlled trials. World J Surg Oncol. 2014;12:122.
Liu H, Lu DH, Wang L, Shi G, Song H, Wang L. Robotic Surgery for Benign Gynaecological Disease. Cochrane
Database Syst Rev. December 11, 2014.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008978.pub3/full. Accessed August 18, 2016.
Medscape. FDA Investigates Robotic Surgery System After Adverse Event Spike. April 30, 2013
http://www.medscape.com/viewarticle/803339. Accessed August 18, 2016.
Quass AM, Einarssen JI, Srouji S, Gargiulo AR, Robotic Myomectomy: A review of indications and
techniques. Rev Obstet Gynecol. 2010;3(4):185 – 191.
Robertson C, Close A, Fraser C, et al. Relative effectiveness of robot-assisted and standard laparoscopic
prostatectomy as alternatives to open radical prostatectomy for treatment of localised prostate cancer: A
systematic review and mixed treatment comparison meta-analysis. BJU Int. 2013;112(6):798 – 812.
Shen WS, Xi HQ, Chen L, Wei B. A meta-analysis of robotic versus laparoscopic gastrectomy for gastric
cancer. Surg Endosc. 2014;28(10):2795 – 802.
Shi G, Lu D, Liu Z, Liu D, Zhou X. Robotic Assisted Surgery for Gynaecological Cancer. Cochrane Database
Syst Rev. December 11, 2014. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008640.pub3/full.
Accessed August 18, 2016.
Tan A, Ashrafian H, Scott AJ. Robotic surgery: disruptive innovation or unfulfilled promise? A systematic
review and meta-analysis of the first 30 years. Surg Endosc. February 19, 2016 (Epub ahead of print)
Wilensky GR. Robotic surgery: an example of when newer is not always better but clearly more expensive.
Milbank Q. 2016;94(1):43 – 6.
Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs. laparoscopic hysterectomy among women
with benign gynecologic disease. JAMA. 2013;309(7):689 – 98.
8
Zakhari A, Czuzoj-Shulman N, Spence AR, Gotlieb WH, Abenhaim HA. Laparoscopic and robot-assisted
hysterectomy for uterine cancer: a comparison of costs and complications. Am J Obstet Gynecol.
2015;213(5):665.e1 – 7.
Clinical trials
Searched clinicaltrials.gov on August 18, 2016, using “robotic assisted surgery” and “robotic surgery.” | 55
Open Studies, four (4) relevant.
International Study Group for Minimally Invasive Surgery for Gastric Cancer. Robotic, Laparoscopic and
Open Surgery for Gastric Cancer Compared on Surgical, Clinical and Oncological Outcomes.
ClinicalTrials.gov website.
https://clinicaltrials.gov/ct2/show/NCT02325453?term=%22robotic+surgery%22&recr=Open&rank=10.
Last updated April 10, 2016. Accessed August 18, 2016.
International Study Group for Minimally Invasive Surgery for Gastric Cancer. Robotic, Laparoscopic and
Open Gastrectomy Compared on Short and Long Term Outcomes (IMIGASTRICII). ClinicalTrials.gov website.
https://clinicaltrials.gov/ct2/show/NCT02751086?term=%22robotic+surgery%22&recr=Open&rank=29.
Last updated April 21, 2016. Accessed August 18, 2016.
Karolinska Institutet. Robotic Versus Abdominal Surgery for Endometrial Cancer (RASHEC).
ClinicalTrials.gov website.
https://clinicaltrials.gov/ct2/show/NCT01847703?term=%22robotic+surgery%22&recr=Open&rank=17.
Last updated March 16, 2015. Accessed August 18, 2016.
UMC Utrecht. Robot-assisted Thoraco-laparoscopic Esophagectomy Versus Open Transthoracic
Esophagectomy (ROBOT). ClinicalTrials.gov website.
https://clinicaltrials.gov/ct2/show/NCT01544790?term=%22robotic+surgery%22&recr=Open&rank=35.
Last updated October 7, 2014. Accessed August 18, 2016.
Centers for Medicare & Medicaid Services (CMS) national coverage determination
No NCDs found as of the writing of this policy.
Local Coverage Determinations
No LCDs found as of the writing of this policy.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill
accordingly.
CPT Code
S2900
Description
Surgical techniques requiring use of robotic surgical system (list
separately in addition to code for primary procedure)
Comment
NOT FOR USE WITH
MEDICARE CLAIMS
9
55866
Laparoscopy, surgical prostatectomy, retropubic, radical;
including nerve sparing, includes robotic experience when
performed
ICD-10 Code
Description
Comment
Description
Comment
Diagnoses not specified
HCPCS Level
II
N/A
10