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.
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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.
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
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
- 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
- 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)
- 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
- Imaging: Conventional x-rays do not show bone pathology that can explain the loss of motion
From Appendix table
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
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
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
| 22505 | Manipulation of spine requiring anesthesia, any region |
| 00600 | Anesthesia for procedures on cervical spine and cord; not otherwise specified |
| 00604 | Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position |
| 00620 | Anesthesia for procedures on thoracic spine and cord, not otherwise specified |
| 00625 | Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation |
| 00626 | Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation |
| 00630 | Anesthesia for procedures in lumbar region; not otherwise specified |
| 00632 | Anesthesia for procedures in lumbar region; lumbar sympathectomy |
| 00635 | Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture |
| 00640 | Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine |
| 00670 | Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) |
| 27570 | Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) |
| 01320 | Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of knee and/or popliteal area |
| 01380 | Anesthesia for all closed procedures on knee joint |
| 01382 | Anesthesia for diagnostic arthroscopic procedures of knee joint |
| 01390 | Anesthesia for all closed procedures on upper ends of tibia, fibula, and/or patella |
| 01999 | Unlisted anesthesia procedure(s) |
| 99152 | Moderate sedation services by same physician; initial 15 minutes; patient age 5 years or older |
| 99153 | each additional 15 minutes intraservice time (add-on) |
| 99156 | Moderate sedation by other practitioner; initial 15 minutes |
| 99157 | each additional 15 minutes intraservice time (add-on) |
| M24.661 - M24.669 | Ankylosis 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 |
| 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 - M24.659 | Diseases of musculoskeletal system and connective tissue [other than those listed as covered] |
| M24.671 - M26.59 | Diseases of musculoskeletal system and connective tissue ranges |
| M26.70 - M72.9 | Other musculoskeletal disease ranges |
| M75.100 - M99.9 | Musculoskeletal conditions ranges |
| 23700 | Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) |
| 01610 | Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla |
| 01620 | Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint |
| 01622 | Anesthesia for diagnostic arthroscopic procedures of shoulder joint |
| 01630 | Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified |
| 01999 | Unlisted anesthesia procedure(s) |
| 99152 | Moderate sedation services by same physician; initial 15 minutes; patient age 5 years or older |
| 99153 | each additional 15 minutes intraservice time (add-on) |
| 99156 | Moderate sedation by other practitioner; initial 15 minutes |
| 99157 | each additional 15 minutes intraservice time (add-on) |
| M75.00 - M75.02 | Adhesive capsulitis of shoulder [only if X-rays do not show bone pathology that can explain the loss of motion] |
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) |
| M26.601 - M26.69 | Temporomandibular 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 - S03.02xS | Dislocation of jaw |
| 24300 | Manipulation, elbow, under anesthesia |
| 25259 | Manipulation, wrist, under anesthesia |
| 26340 | Manipulation, finger joint, under anesthesia, each joint |
| 26341 | Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord |
| 27198 | Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation ... with manipulation, requiring more than local anesthesia |
| 27275 | Manipulation, hip joint, requiring general anesthesia |
| 27860 | Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) |
| 01160 | Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint |
| 01170 | Anesthesia for open procedures involving symphysis pubis or sacroiliac joint |
| 01200 | Anesthesia for procedures on bony pelvis |
| 01202 | Anesthesia for arthroscopic procedures of hip joint |
| 01220 | Anesthesia for all closed procedures involving upper two-thirds of femur |
| 01250 | Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of upper leg |
| 01462 | Anesthesia for all closed procedures on lower leg, ankle, and foot |
| 01464 | Anesthesia for arthroscopic procedures of ankle and/or foot |
| 01470 | Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; not otherwise specified |
| 01710 | Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwise specified |
| J0775 | Injection, 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
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.
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 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
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 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 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.
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 / Source | Key finding |
|---|---|
| Kohlbeck et al (2005) prospective cohort | MAM 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) RCT | Manipulation did not add effectiveness to exercise program for frozen shoulder at 1 year |
| Spitler et al. (2018) - post-traumatic elbow stiffness | n=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 effect | n=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 RCR | Matched 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 PFA | Systematic 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
Policy effective date
Policy last reviewed
Scheduled next review date
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