Blue Cross Blue Shield - Iowa MUA Coverage Update

Coverage Summary

Scope: This policy addresses Manipulation Under Anesthesia (MUA) for multiple joint and spine indications and specifies clinical criteria for medically necessary use versus investigational use. Status: CURRENT.

Overview: MUA is considered medically necessary for adhesive capsulitis (frozen shoulder) when the specified criteria are met (pain/stiffness limiting activities of daily living; exclusion of other etiologies including significant glenohumeral osteoarthritis; and documented failure of conservative therapy including ≥3 weeks of analgesics/NSAIDs/oral corticosteroids, ≥6 weeks of physical therapy/home exercise, and an intra-articular corticosteroid injection).

MUA is also considered medically necessary for arthrofibrosis/stiffness after total knee arthroplasty (TKA) when criteria are met (pain/stiffness limiting activities of daily living; exclusion of other causes such as malpositioned/incorrectly sized arthroplasty components; and failure of conservative therapy including ≥3 weeks of analgesics/NSAIDs and ≥6 weeks of physical therapy/home exercise).

Investigational: MUA for the spine (chronic spinal, sacroiliac, pelvic pain) and MUA for multiple other joints — including ankle, elbow, finger, hand, hip, pelvis, temporomandibular joint (TMJ) except the surgical reduction/dislocation exception, toe, wrist, and multi-joint procedures — is considered investigational because evidence is insufficient.

Review cadence and last review: Policy is reviewed annually; most recent literature update through May 2025 and last review date listed as 2025-06 (document revision line shows a prior revision in January 2023).

Key thresholds & quick facts from policy

Optimal timing for post‑TKA MUA4–12 weeks post‑operatively

Early vs late elbow MUA windowWithin 3 months associated with much greater improvement vs after 3 months

Reported overall complication rate for primary knee MUA~1%

Proportion achieving >90° flexion after knee MUA87% achieved >90° (Randsborg et al. 2020)

Count of CPT codes listed10 CPT codes listed for MUA procedures

Shoulder - Adhesive Capsulitis (Medically Necessary / Investigational)

Manipulation Under Anesthesia for Adhesive Capsulitis of the Shoulder - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Pain and stiffness with limited range of motion which significantly interfere with activities of daily living.
Other etiologies of shoulder pain have been excluded by clinical history, physical exam, and appropriate imaging studies to exclude significant glenohumeral osteoarthritis.
Failure of conservative treatment regimen (all required):
- Trial of acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and/or oral corticosteroids for at least 3 weeks.
  Document medications, doses, and dates.

Knee - Post-TKA Stiffness (Medically Necessary / Investigational)

Manipulation Under Anesthesia for Stiffness after Total Knee Arthroplasty (TKA) - Medically Necessary

Knee manipulation under anesthesia may be considered medically necessary when ALL the following criteria are met:

ALL of the following

Pain and stiffness with limited range of motion which significantly interfere with activities of daily living
Other etiologies of knee pain/stiffness have been excluded by clinical history, physical exam, and appropriate imaging studies (e.g., mispositioned/incorrectly sized arthroplasty components)
Failure of a conservative treatment regimen, including acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) for at least 3 weeks and physical therapy/home exercise program for at least 6 weeks

Manipulation Under Anesthesia for Stiffness after TKA - Investigational

Spine and Other Joints (Investigational)

Manipulation Under Anesthesia of the Spine - Investigational

Spinal MUA is considered investigational:

ALL of the following

Spinal manipulation under anesthesia for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac joint pain

Manipulation Under Anesthesia for Other Joints - Investigational

MUA for the following joints and situations is considered investigational for all indications, single or serial sessions:

ALL of the following

Ankle
Elbow

Evidence-based Conclusions by Indication

General evidence-based conclusions by indication: summarized below reflect the policy's synthesis of randomized trials, systematic reviews, comparative and noncomparative observational studies and specialty guidance.

Shoulder (adhesive capsulitis/frozen shoulder): Evidence includes RCTs, nonrandomized comparative and observational studies showing consistent improvement in pain, function and range of motion (ROM) and improvements in Oxford Shoulder Score (OSS). AAOS includes MUA as an option for adhesive capsulitis. Key studies cited include Woods et al. 2017, Bidwai 2016, and the multicenter UK FROST RCT (Rangan et al. 2020) and other comparative series; overall evidence is judged sufficient for improvement in net health outcome when specified criteria are met.

Knee (post-TKA arthrofibrosis/stiffness): Evidence includes a systematic review (Gu et al. 2018) and multiple observational studies (eg, Randsborg et al. 2020, Lim et al. 2021, Pierce et al. 2017) demonstrating improved ROM and patient satisfaction after MUA. Systematic review findings support performing MUA optimally between 4 and 12 weeks post-operatively and report an overall complication rate of about 1%. The evidence is judged sufficient for improvement in net health outcome for appropriately selected post‑TKA patients meeting criteria.

Temporomandibular joint (TMJ): Evidence is limited to a small prospective noncomparative study (Foster 2000) with no RCTs or long-term follow-up; results are mixed and insufficient to demonstrate net health benefit for TMJ indications.

First MTPJ (toe after hallux valgus/hallux rigidus surgery): Evidence consists of small noncomparative observational studies (Ajwani 2018; Feuerstein 2016) showing some ROM and pain improvement but no RCTs and limited sample sizes — evidence is insufficient.

Elbow (post‑traumatic or post‑surgical stiffness): Observational data (Spitler 2018 and others) suggest greater ROM gains when MUA is performed within 3 months of injury/surgery (early window favored); complications and need for further procedures reported. Overall evidence remains insufficient for definitive conclusions.

Codes and Billing

Covered CPT codes for manipulation under anesthesia / related anesthesiaCPTCovered

21073	Manipulation of temporomandibular joint, therapeutic, requiring anesthesia service
22505	Manipulation of spine requiring anesthesia, any region
00640	Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine
27860	Manipulation of ankle under general anesthesia
24300	Manipulation elbow under anesthesia
27275	Manipulation of hip joint requiring general anesthesia
25259	Manipulation wrist under anesthesia
26340	Manipulation finger joint under anesthesia each joint
23700	Manipulation under anesthesia shoulder joint including application of fixation apparatus (dislocation excluded)
27570	Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

Service type / place of servicemixed

SVC	Type of Service: Surgical
POS	Place of Service: Outpatient/Inpatient

Codingmixed

No codes listed

Provider Actions & Documentation Requirements

Documentation Required

Document exclusion of other etiologies

Document clinical history, physical examination findings, and relevant imaging that rule out other causes of joint pain or stiffness prior to MUA (for shoulder, exclude significant glenohumeral osteoarthritis; for knee, exclude malpositioned or incorrectly sized arthroplasty components).

Documentation Required

Document conservative therapy failure

Document failure of the required conservative regimen before shoulder or knee MUA. For shoulder adhesive capsulitis: acetaminophen, NSAIDs, and/or oral corticosteroids for at least 3 weeks; a physical therapy/home exercise program for at least 6 weeks; and an intra‑articular corticosteroid injection. For knee post‑TKA stiffness: acetaminophen and/or NSAIDs for at least 3 weeks and a physical therapy/home exercise program for at least 6 weeks.

Definitions

Arthrofibrosis: A complication of injury or trauma in which an excessive scar tissue response causes painful restriction of joint motion, with scar tissue forming within the joint and surrounding soft tissue spaces and persisting despite rehabilitation exercises and stretches.

Manipulation Under Anesthesia (MUA): A procedure consisting of mobilization, stretching, and traction performed while the patient is sedated (general anesthesia or moderate sedation) to improve joint range of motion by breaking up fibrous and scar tissue.

ROM (Range of Motion): The movement potential of a joint, typically measured in degrees and used to quantify functional joint mobility before and after interventions.

OSS (Oxford Shoulder Score): A patient‑reported outcome measure assessing shoulder pain and function commonly used in studies of adhesive capsulitis and shoulder interventions.

Revision History

2023-01revised

Revised: January 2023 — Policy was revised (annual review in January 2023) with updates to coverage conclusions and criteria; literature update process continued through May 2025 per subsequent evidence updates.

2024-06annual_review

June 2024: Annual Review; Policy Renewed — policy underwent the routine annual review and was renewed in June 2024 per policy history.

2025-06annual_reviewLatest

Policy reviewed with literature update through May 2025 and last_review date set to 2025-06; conclusions and coverage criteria for various joints and indications were stated following the literature update through May 2025.

OpenPayer

Manipulation under Anesthesia

Coverage Summary

Shoulder - Adhesive Capsulitis (Medically Necessary / Investigational)

Knee - Post-TKA Stiffness (Medically Necessary / Investigational)

Spine and Other Joints (Investigational)

Evidence-based Conclusions by Indication

Codes and Billing

Provider Actions & Documentation Requirements

Definitions

Revision History