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    v1.0.31
    OpenPayerPolicy UpdatesAnesthesiologyAetna MUA Coverage & Prior Auth Guidance | OpenPay…
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    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentAetnaPolicy 0204

    Manipulation Under Anesthesia- CPB-0204

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    Defines medical necessity, experimental/investigational indications, limitations/exclusions, and billing code guidance for manipulation under general anesthesia for various joints (knee, shoulder, temporomandibular joint, spine, other joints). This part (1 of 2) includes policy statements, experimental exclusions, background evidence, and extensive CPT/HCPCS/ICD-10 code lists and guidance.

    Policy Summary
    PayerAetna
    PolicyManipulation Under Anesthesia- CPB-0204
    Policy CodePolicy 0204
    Change TypeNo material change
    Effective DateMar 12, 1998
    Last ReviewMar 29, 2023
    Next Review DateFeb 8, 2024
    Key ActionDocument that selection criteria are met for covered indications and provide objective ROM measurements, prior conservative therapy, radiographs excluding bone pathology, and obtain prior authorization as required.
    SourceLink
    POLICY UPDATE CHANGES

    No material changes — has_material_change=false

    3Covered Indications (listed)
    3Experimental/Investigational Indications (examples listed)
    40+Codes referenced (CPT/ICD-10/HCPCS)
    12 wksConservative care duration for adhesive capsulitis
    4-6 mosKnee MUA timing window

    Coverage Summary

    Policy Number 0204 — Manipulation Under General Anesthesia (MUA): This policy defines medical necessity and experimental/investigational indications for MUA across multiple joints. Coverage stance is mixed: select indications (knee arthrofibrosis after TKA/surgery/fracture; chronic refractory frozen shoulder; temporomandibular joint disorders) are considered medically necessary when specific criteria are met, while others (including spinal MUA and MUA for many other joints) are experimental/investigational. Key dates: Effective: 1998-03-12; Last review: 2023-03-29; Next review: 2024-02-08. Key statistics from the brief: 3 covered indications listed, 3 example experimental indications, and >40 CPT/ICD-10/HCPCS codes referenced.

    Quick Criteria & Thresholds
    Knee ROM threshold< 90 degrees flexion
    Frozen shoulder ROM loss>= 50% reduction in both active and passive ROM vs unaffected shoulder
    Timing window for knee arthrofibrosis MUA4 weeks to 6 months after surgery or trauma
    Conservative care duration for adhesive capsulitis>= 12 weeks of conservative management (analgesics/steroids, PT/exercises, and injection or hydrodilatation)
    Policy Summary
    PayerAetna
    PolicyManipulation Under Anesthesia- CPB-0204
    Policy CodePolicy 0204
    Change TypeNo material change
    Effective DateMar 12, 1998
    Last ReviewMar 29, 2023
    Next Review DateFeb 8, 2024
    Key ActionDocument that selection criteria are met for covered indications and provide objective ROM measurements, prior conservative therapy, radiographs excluding bone pathology, and obtain prior authorization as required.
    SourceLink
    On This Page
    Coverage SummaryMedical-Necessity CriteriaExperimental / Not Medically NecessaryCoding GuidanceProvider Actions & Billing ImpactBackground & EvidenceRevision History
    National Academy serial MUA thresholdPatient regains >= 80% of normal biomechanical function during first procedure and retains >= 80% post-MUA

    Medical-Necessity Criteria

    Medical Necessity

    ANY of the following

    • Arthrofibrosis of knee following total knee arthroplasty, knee surgery, or fracture

      (see Appendix)

    • Chronic, refractory frozen shoulder (adhesive capsulitis)

      (see Appendix)

    • Temporomandibular joint disorders
    Top-level: Medical Necessity indications (any one qualifies)

    From policy: MUA considered medically necessary for the following indications

    Medically Necessary Indications (Appendix table)

    ONE of the following conditions

    • Knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture

      • Knee ROM threshold: Person has less than 90 degrees range of motion (ROM)< 90 degrees
      • Timing: 4 weeks to 6 months after surgery or trauma4 weeks to 6 months

        No progression or regression in ROM

    • Frozen shoulder (adhesive capsulitis)

      • Duration: Adhesive capsulitis documented by restricted active and passive glenohumeral and scapulothoracic motion for at least 1-month duration which has either reached a plateau or worsened>= 1 month

    Policy Limitations and Exclusions

    Policy Limitations and Exclusions - Notes

    • Exclusion: examinations under anesthesia: Policy does not apply to examinations under anesthesia
    • Exclusion: setting fractures or complete joint dislocations: Policy does not apply to setting fractures or complete joint dislocations under anesthesia
    These are explicit exclusions from the policy scope

    Experimental / Not Medically Necessary

    Experimental and Investigational (Not Medically Necessary)

    • SMUA: Spinal manipulation under general anesthesia (SMUA) — not established as safe or effective for musculoskeletal disorders such as neck and back problems; selection criteria, outcomes, long-term benefits not established
    • MUA for cruciate/multiple/other joints: MUA for injuries of the cruciate ligaments, of multiple joints, for disorders of other body joints (e.g., ankle, elbow, finger, hip, pelvis, toe, and wrist), or for osteoporotic thoracolumbar vertebral compression fracture
    • MUA after collagenase for Dupuytren's: MUA of the hand/fingers after collagenase clostridium histolyticum (Xiaflex) injections for Dupuytren's contracture
    Policy stance: Claims for these indications are considered experimental/investigational and may be denied

    These indications are considered experimental/investigational; claims may be denied. Specifically, the policy lists spinal manipulation under general anesthesia (SMUA), MUA for cruciate ligament injuries, multiple-joint or many other joint disorders (e.g., ankle, elbow, finger, hip, pelvis, wrist), and MUA after Xiaflex injections for Dupuytren's contracture as examples where effectiveness has not been established and denial is possible without supporting evidence.

    Coding Guidance

    MUA of spine - CPT codes not covered for indications listed in the CPB (not all-inclusive)CPTNot Covered
    22505Manipulation of spine requiring anesthesia, any region
    Anesthesia CPT codes related to spinal MUACPT
    00600Anesthesia for procedures on cervical spine and cord; not otherwise specified
    00604Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position
    00620Anesthesia for procedures on thoracic spine and cord, not otherwise specified
    00625Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation
    00626Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation
    00630Anesthesia for procedures in lumbar region; not otherwise specified
    00632Anesthesia for procedures in lumbar region; lumbar sympathectomy
    00635Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture
    00640Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine
    00670Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures)
    1–10 of 15
    1/2
    MUA of knee - CPT codes covered if selection criteria are metCPTCovered
    27570Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
    Anesthesia CPT codes related to knee MUACPT
    01320Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of knee and/or popliteal area
    01380Anesthesia for all closed procedures on knee joint
    01382Anesthesia for diagnostic arthroscopic procedures of knee joint
    01390Anesthesia for all closed procedures on upper ends of tibia, fibula, and/or patella
    01999Unlisted anesthesia procedure(s)
    99152Moderate sedation services by same physician; initial 15 minutes; patient age 5 years or older
    99153each additional 15 minutes intraservice time (add-on)
    99156Moderate sedation by other practitioner; initial 15 minutes
    99157each additional 15 minutes intraservice time (add-on)
    ICD-10 codes covered if selection criteria are met (knee arthrofibrosis and related fractures/status)ICD-10Covered
    M24.661 - M24.669Ankylosis of joint, knee [arthrofibrosis following total knee arthroplasty]
    S72.401+ - S72.499+Fracture of lower end of femur
    S79.101+ - S79.199+Unspecified physeal fracture of lower end of femur
    S82.001+ - S82.099+Fracture of patella
    S82.101+ - S82.156+Fracture of upper end of tibia and other fracture of upper end of tibia
    S82.191+ - S82.199+Fracture of upper end of tibia and other fracture ranges
    S82.401+ - S82.499+Fracture of fibula
    S83.200+ - S83.32+Tear of meniscus, current injury and tear of articular cartilage of knee, current
    S89.001+ - S89.099+Physeal fracture of upper end of tibia
    S89.201+ - S89.299+Physeal fracture of upper end of fibula
    1–10 of 11
    1/2
    ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)ICD-10Not Covered
    S86.001+ - S86.999+Injury of muscle, fascia and tendon at lower leg level
    S96.001+ - S96.999+Injury of muscle and tendon at ankle and foot level
    M00.011 - M24.659Diseases of musculoskeletal system and connective tissue [other than those listed as covered]
    M24.671 - M26.59Diseases of musculoskeletal system and connective tissue ranges
    M26.70 - M72.9Other musculoskeletal disease ranges
    M75.100 - M99.9Musculoskeletal conditions ranges
    MUA of shoulder - CPT codes covered if selection criteria are metCPTCovered
    23700Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
    Anesthesia CPT codes related to shoulder MUACPT
    01610Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla
    01620Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint
    01622Anesthesia for diagnostic arthroscopic procedures of shoulder joint
    01630Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified
    01999Unlisted anesthesia procedure(s)
    99152Moderate sedation services by same physician; initial 15 minutes; patient age 5 years or older
    99153each additional 15 minutes intraservice time (add-on)
    99156Moderate sedation by other practitioner; initial 15 minutes
    99157each additional 15 minutes intraservice time (add-on)
    ICD-10 codes covered if selection criteria are met (shoulder adhesive capsulitis)ICD-10Covered
    M75.00 - M75.02Adhesive capsulitis of shoulder [only if X-rays do not show bone pathology that can explain the loss of motion]
    MUA of temporomandibular joint - CPT codes covered if selection criteria are metCPTCovered
    21073Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
    Anesthesia CPT codes related to TMJ MUACPT
    00170Anesthesia for intraoral procedures, including biopsy; not otherwise specified
    00190Anesthesia for procedures on facial bones or skull; not otherwise specified
    01999Unlisted anesthesia procedure(s)
    ICD-10 codes covered if selection criteria are met (TMJ disorders and related facial fractures/dislocations)ICD-10Covered
    M26.601 - M26.69Temporomandibular joint disorders
    S02.400+ - S02.413+Fracture of malar, maxillary and zygoma bones, unspecified and LeFort fracture
    S02.600+ - S02.69x+Fracture of mandible
    S03.00xA - S03.02xSDislocation of jaw
    MUA of other joints - CPT codes not covered for indications listed in the CPB (not all-inclusive)CPTNot Covered
    24300Manipulation, elbow, under anesthesia
    25259Manipulation, wrist, under anesthesia
    26340Manipulation, finger joint, under anesthesia, each joint
    26341Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord
    27198Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation ... with manipulation, requiring more than local anesthesia
    27275Manipulation, hip joint, requiring general anesthesia
    27860Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)
    Anesthesia CPT codes related to other joints MUACPT
    01160Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint
    01170Anesthesia for open procedures involving symphysis pubis or sacroiliac joint
    01200Anesthesia for procedures on bony pelvis
    01202Anesthesia for arthroscopic procedures of hip joint
    01220Anesthesia for all closed procedures involving upper two-thirds of femur
    01250Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of upper leg
    01462Anesthesia for all closed procedures on lower leg, ankle, and foot
    01464Anesthesia for arthroscopic procedures of ankle and/or foot
    01470Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; not otherwise specified
    01710Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwise specified
    1–10 of 20
    1/2
    Other HCPCS (drug) related to CPBHCPCS
    J0775Injection, collagenase, clostridium histolyticum, 0.01 mg

    Billing: report the joint-specific manipulation CPT code (for example, 27570 for knee, 23700 for shoulder, 21073 for TMJ, or other joint-specific CPTs) and also report related anesthesia CPT codes and moderate sedation codes as applicable (examples include anesthesia codes listed in the policy and moderate sedation codes 99152/99153/99156/99157). Ensure documentation supports the billed services and code selection.

    Provider Actions & Billing Impact

    Documentation Required

    Selection criteria documentation

    Document that selection criteria are met for covered indications (eg, arthrofibrosis after TKA, chronic refractory adhesive capsulitis, TMJ disorders) and record relevant diagnostic findings such as measured ROM, prior conservative therapy attempts, and radiographs excluding bone pathology.

    Documentation Required

    Document joint-specific ROM and functional impairment

    Record objective active and passive range-of-motion measurements and functional limitations. For adhesive capsulitis include comparison of active and passive ROM to the unaffected shoulder (document at least a 50% reduction in both active and passive ROM when applicable) and note duration of restricted motion.

    Prior Authorization

    Prior authorization likely required per payer policy

    Prior authorization is commonly required; include documentation of failed conservative management (eg, >=12 weeks for adhesive capsulitis), timing relative to surgery/trauma (eg, knee: 4 weeks to 6 months after surgery/trauma and <90 degrees ROM), and measured ROM values to support medical necessity.

    • Failed conservative management (duration and therapies tried, e.g., analgesics/corticosteroids, physical therapy, injections)
    • Timing relative to surgery or injury (eg, knee 4 weeks to 6 months; knee <90° ROM)
    • Objective ROM measurements and comparison to unaffected side
    Billing Rule

    Use of related anesthesia and sedation codes

    When billing, report the appropriate manipulation CPT for the joint and also report related anesthesia CPT codes and moderate sedation codes as applicable (codes for shoulder, knee, TMJ, spine, and other joints and the listed anesthesia/moderate sedation codes are provided in the policy).

    Denial Risk

    Denial risk for experimental indications

    Claims for experimental/investigational indications may be denied. Examples called out in the policy include spinal manipulation under anesthesia (SMUA), MUA for cruciate ligament injuries or multiple/other non-listed joints, and MUA of the hand/fingers after Xiaflex (collagenase) injections for Dupuytren's contracture.

    Denial Risk

    Denial risk if conservative therapy not documented or timing outside window

    There is a denial risk if documentation does not demonstrate required conservative therapy or if timing/ROM criteria are not met. For adhesive capsulitis document >=12 weeks of failed conservative care; for post‑TKA knee arthrofibrosis document <90° ROM in the 4‑ to 6‑month window after surgery/trauma.

    Documentation Required

    Exclude non-applicable procedures

    If the procedure was performed for reasons excluded by the policy, document that explicitly (examples: examination(s) under anesthesia, setting fractures or complete joint dislocations under anesthesia) to justify non‑applicability of the MUA coverage criteria.

    Background & Evidence

    Background: Manipulation under anesthesia (MUA) is a noninvasive technique intended to break fibrous adhesions and improve range of motion by taking advantage of muscle relaxation under anesthesia. Evidence is mixed: some case series and cohort studies report short-term improvements for indications such as frozen shoulder and post-TKA arthrofibrosis, but higher-quality trials are limited and results vary. Spinal manipulation under anesthesia (SMUA) has low-quality evidence and reported safety concerns (including rare but serious complications), and guidelines generally do not recommend SMUA.

    Study / SourceKey finding
    Kohlbeck et al (2005) prospective cohortMAM showed short-term improvements over SMT but differences attenuated at 1 year; randomized trials warranted
    BMJ Clinical Evidence (Speed, 2006)Concluded MUA plus intra-articular injection likely beneficial for frozen shoulder based on small RCTs
    Kivimäki et al (2007) RCTManipulation did not add effectiveness to exercise program for frozen shoulder at 1 year
    Spitler et al. (2018) - post-traumatic elbow stiffnessn=45; significant improvement in flexion arc when MUA performed within 3 months (mean +38.3°) vs after 3 months (mean +3.1°); Level IV evidence
    Ko et al. (2021) - comorbidities effectn=281; diabetes mellitus associated with slower ROM recovery and higher non-successful MUA rates; poorer outcomes with DM and thyroid disorders
    Wang et al. (2022) - open vs arthroscopic RCRMatched cohorts n=3,266 each; higher rates of MUA within 2 and 5 years after open RCR vs arthroscopic RCR (1.65% vs 0.95% at 2 years)
    Familiari et al. (2023) - inlay vs onlay PFASystematic review of 42 studies (2,552 patients); higher number of MUA and higher complications in inlay group; Level IV

    MUA: Manipulation under general anesthesia — joint manipulation performed while the patient is under general anesthesia or monitored anesthesia care.

    SMUA: Spinal manipulation under anesthesia — manipulation of the spine performed under anesthesia; considered experimental/investigational by this policy.

    Adhesive capsulitis (frozen shoulder): a clinical diagnosis characterized by restricted active and passive glenohumeral and scapulothoracic motion with pain and functional limitation; policy threshold requires >= 1 month of restricted motion and >= 50% reduction in active and passive ROM compared with the unaffected shoulder.

    Revision History

    1998-03-12Effective

    Policy effective date

    2023-03-29Last reviewLatest

    Policy last reviewed

    2024-02-08Next review

    Scheduled next review date

  1. ROM reduction: Significant reduction in ROM: at least a 50% reduction in both active and passive ROM compared with the unaffected shoulder>= 50% reduction in active and passive ROM vs unaffected shoulder
  2. Functional impairment: Causing impaired function (examples: limited reaching overhead or across chest; limited rotation such as unable to scratch back or difficulty putting on a coat)
  3. Conservative care: Failure of conservative management for at least 12 weeks, including analgesics or corticosteroids, physical therapy or therapeutic exercises, and subacromial corticosteroid injection or hydrodilatation (arthrographic distension, hydrodilation, hydroplasty)>= 12 weeks
  4. Imaging: Conventional x-rays do not show bone pathology that can explain the loss of motion
    5. Top-level instruction: MUA is considered medically necessary for the listed conditions when ALL specified criteria in the relevant nested group are met

    From Appendix table