Aetna MUA Coverage & Prior Auth Guidance

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)

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

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

Coding Guidance

MUA of spine - CPT codes not covered for indications listed in the CPB (not all-inclusive)CPTNot Covered

22505

Manipulation of spine requiring anesthesia, any region

Anesthesia CPT codes related to spinal MUACPT

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)

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MUA of knee - CPT codes covered if selection criteria are metCPTCovered

27570

Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

Anesthesia CPT codes related to knee MUACPT

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)

ICD-10 codes covered if selection criteria are met (knee arthrofibrosis and related fractures/status)ICD-10Covered

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

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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 - M24.659	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

MUA of shoulder - CPT codes covered if selection criteria are metCPTCovered

23700

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

Anesthesia CPT codes related to shoulder MUACPT

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)

ICD-10 codes covered if selection criteria are met (shoulder adhesive capsulitis)ICD-10Covered

M75.00 - M75.02

Adhesive 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

21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

Anesthesia CPT codes related to TMJ MUACPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified
00190	Anesthesia for procedures on facial bones or skull; not otherwise specified
01999	Unlisted anesthesia procedure(s)

ICD-10 codes covered if selection criteria are met (TMJ disorders and related facial fractures/dislocations)ICD-10Covered

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

MUA of other joints - CPT codes not covered for indications listed in the CPB (not all-inclusive)CPTNot Covered

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)

Anesthesia CPT codes related to other joints MUACPT

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

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Other HCPCS (drug) related to CPBHCPCS

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

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.

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

1998-03-12Effective

Policy effective date

2023-03-29Last reviewLatest

Policy last reviewed

2024-02-08Next review

Scheduled next review date

OpenPayer

Manipulation Under Anesthesia- CPB-0204