CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Manipulation Under Anesthesia (MUA)

Defines medical coverage stance for manipulation under anesthesia (MUA) for Medicare Advantage and Commercial products, specifying indications considered not covered/not medically necessary (chiefly chronic spinal and multi-joint MUA and serial sessions) and limited medically necessary indications (fractures, completely dislocated joints, adhesive capsulitis, post–total joint replacement fibrosis).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyManipulation Under Anesthesia (MUA)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 18, 2016

Next Review Date

Key ActionVerify member-specific benefits and contract language because benefits may vary between groups and contracts.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1CPT code listed as not covered/not medically necessary

4Medically necessary exception indications listed

2Product lines addressed

Coverage Summary

This policy defines the coverage stance for Manipulation Under Anesthesia (MUA) for both Medicare Advantage and Commercial products. It summarizes product-specific determinations (see Medicare Advantage and Commercial Products sections) and lists indications considered not covered/not medically necessary and those that may be medically necessary as exceptions. Effective: 05|18|2016. Last review: 04|19|2023.

Medical Necessity Criteria (by product)

Medicare Advantage - Coverage Determinations

Coverage determinations for MUA under Medicare Advantage:

ALL of the following

Spinal manipulation and manipulation of other joints performed during the procedure (e.g., hip joint), spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered not covered for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain because evidence is insufficient to determine the effects of the technology on health outcomes.
Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions are considered not covered because evidence is insufficient to determine the effects of the technology on health outcomes.
Manipulation under anesthesia (MUA) involving multiple body joints is considered not covered for treatment of chronic pain because evidence is insufficient to determine the effects of the technology on health outcomes.
Medically necessary exceptions
- Manipulation under anesthesia for fractures may be considered medically necessary.
- Manipulation under anesthesia for completely dislocated joints may be considered medically necessary.
- Manipulation under anesthesia for adhesive capsulitis (e.g., frozen shoulder) may be considered medically necessary.
- Manipulation under anesthesia for fibrosis of a joint that may occur following total joint replacement may be considered medically necessary.

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Commercial Products - Coverage Determinations

Coverage determinations for Commercial Products:

ALL of the following

Spinal manipulation and manipulation of other joints performed during the procedure (e.g., hip joint), spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered not medically necessary for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain because evidence is insufficient to determine the effects of the technology on health outcomes.
Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions are considered not medically necessary because evidence is insufficient to determine the effects of the technology on health outcomes.
Manipulation under anesthesia (MUA) involving multiple body joints is considered not medically necessary for treatment of chronic pain because evidence is insufficient to determine the effects of the technology on health outcomes.
Medically necessary exceptions

Not Covered / Not Medically Necessary

For both Medicare Advantage and Commercial product lines, MUA procedures involving spinal manipulation (including manipulation of other joints during the procedure), spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia with corticosteroid injection are considered not covered / not medically necessary for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain because the evidence is insufficient to determine effects on health outcomes. Serial treatment sessions of spinal manipulation under anesthesia and MUA involving multiple body joints for chronic pain are also considered not covered / not medically necessary for the same reason. CPT code 22505 (Manipulation of spine requiring anesthesia, any region) is listed as not covered/not medically necessary when used for these chronic or multi-joint/serial indications.

Provider Actions & Billing Impact

Documentation Required

Benefit verification

Verify member-specific benefits and contract language (Benefit Booklet, Evidence of Coverage or Subscriber Agreement) because benefits may vary between groups and contracts. For information on member-specific benefits, contact the provider call center or refer to the member's subscriber agreement/certificate or employer agreement. These documents supersede the medical policy and determine coverage and eligibility.

Denial Risk

Claims denial risk for chronic MUA and serial/multi-joint MUA

Claims for spinal MUA, spinal manipulation under joint anesthesia, spinal manipulation after epidural anesthesia with corticosteroid injection, serial (multiple) treatment sessions, or MUA involving multiple body joints for chronic pain are considered not covered / not medically necessary due to insufficient evidence and risk denial. Do not bill CPT 22505 for these chronic pain, serial-session, or multi-joint indications.

22505

Documentation Required

Medically necessary exceptions documentation

When billing MUA for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), or fibrosis of a joint following total joint replacement, document the specific indication and clinical rationale to support medical necessity to avoid denial.

Background

MUA consists of a series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually with general anesthesia or moderate sedation). It is intended to break up fibrous and scar tissue to relieve pain and improve range of motion; anesthesia reduces pain, spasm, and reflex guarding to permit more effective therapy. MUA is an accepted treatment for isolated joint conditions (for example, arthrofibrosis of the knee and adhesive capsulitis), and is used for fracture reduction and dislocations. MUA has been proposed as a treatment for acute and chronic spinal pain when standard care has failed, but scientific evidence for spinal MUA is very limited: no randomized controlled trials have been identified, evidence for serial-session MUA and multi-joint MUA is lacking, and safety outcomes are poorly described. Some practitioners perform MUA in three or more consecutive daily sessions and follow with 4–8 weeks of active rehabilitation, but the efficacy of serial sessions and multi-joint MUA for chronic pain is not established.

Evidence summary

Randomized controlled trials identifiedNone identified

Evidence for chronic spinal and multi-joint MUAInsufficient to determine effects on health outcomes; very limited evidence and no RCTs

Evidence on serial sessions or multiple jointsLacking; efficacy and safety outcomes poorly described

Clinical use with some supported indicationsAccepted for isolated joint conditions (eg, adhesive capsulitis), fractures, dislocations; these are listed as medically necessary exceptions

Manipulation Under Anesthesia (MUA): A series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually with general anesthesia or moderate sedation), potentially including spinal manipulative therapy.

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