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Currentblue cross blue shield - south dakotaPolicy 08.01.20

Manipulation under Anesthesia

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Defines medical necessity, investigational uses, and clinical criteria for manipulation under anesthesia across multiple joints (shoulder, knee, spine, and other joints), summarizes evidence, and references coding. Applies to Wellmark (Blue Cross Blue Shield - South Dakota) members per plan benefits.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyManipulation under Anesthesia

Policy CodePolicy 08.01.20

Change TypeRevised (Jan 2023)Annual Review/Renewed (Jun 2024)

Effective DateApr 1, 2012

Last ReviewJun 1, 2025

Next Review DateN/A

Key ActionDocument clinical history, exam, appropriate imaging and failed conservative therapies with specified durations to support medical necessity prior to MUA.

SourceLink

POLICY UPDATE CHANGES

Policy revised January 2023; last review June 2025 with literature update through May 2025.

Policy underwent Annual Review and was Renewed in June 2024.

ShoulderShoulder: Covered with criteria

KneeKnee post‑TKA: Covered with criteria

SpineSpine: Investigational

Other jointsOther joints: Investigational

1%Knee MUA complication rate

4-8 wksMin. conservative trial before MUA

Coverage Summary

Overview: Policy 08.01.20 (effective April 2012; last review 2025-06-01) addresses Manipulation Under Anesthesia (MUA). Scope defines medical necessity and investigational uses across multiple joints (shoulder, knee, spine, and other joints) and summarizes evidence and coding. High-level coverage stance: mixed — certain indications (adhesive capsulitis of the shoulder and stiffness after total knee arthroplasty) are covered when specific clinical criteria are met; other indications are investigational or insufficiently supported.

Key thresholds and quick facts

Optimal timing for knee MUA post-TKA4-12 weeks post-operatively

Elbow effectiveness windowWithin 3 months of injury or most recent surgery

Typical procedure durationTypically 15-20 minutes

Minimum conservative care trialCommonly minimum 4-8 weeks (and specific regimens: acetaminophen/NSAIDs >=3 weeks; PT >=6 weeks for shoulder/knee)

Key stats/highlights:

• Shoulder (adhesive capsulitis): Covered with defined criteria (failure of specified conservative care).

• Knee (post-TKA arthrofibrosis): Covered with defined criteria; ideal timing 4-12 weeks post-op.

• Spine and other joints (e.g., ankle, elbow, hand, hip, TMJ, toe, wrist, pelvis): Considered investigational due to insufficient evidence.

• Reported overall complication rate for knee MUA in systematic review: ~1%.

Manipulation Under Anesthesia — Shoulder (Adhesive Capsulitis)

Operational note (shoulder): Randomized trials and observational studies show MUA can improve pain, function and range of motion; RCTs (e.g., Rangan et al. 2020) demonstrate improvement though not necessarily superiority at 12 months — evidence considered sufficient when the policy's shoulder criteria are met. Inform patients that comorbidities (notably diabetes mellitus and thyroid disorders) are associated with slower ROM recovery and higher rates of non-successful MUA.

Manipulation Under Anesthesia — Knee (Post-TKA Stiffness)

Evidence summary (knee post-TKA): Systematic review and observational studies report consistent improvement in ROM after MUA, with analyses indicating ideal timing between 4 and 12 weeks post-operatively. Reported complication rate across studies is low (approximately 1%), and MUA is considered to provide net health benefit for arthrofibrosis after TKA when policy criteria are met.

Spine and Other Joints — Investigational / Not Covered

Investigational determinations reflect limited or low-quality evidence: spinal MUA and MUA for many other joints lack RCTs and rely on case series/observational reports, so benefits and harms are uncertain. Examples of joints with insufficient evidence include: TMJ, hip, wrist, hand, finger, ankle, first MTPJ, elbow (when performed after 3 months).

Clinical Context and Evidence Summary

Background / procedural description: Manipulation under anesthesia (MUA) is a series of mobilization, stretching, and traction procedures performed while the individual is sedated (usually general anesthesia or moderate sedation) intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Historically MUA has been used for the spine and other joints; evidence quality varies by indication.

Indication	Evidence Summary
Shoulder (Adhesive capsulitis / frozen shoulder)	RCTs and observational studies show improvements in pain, function, and range of motion (ROM); RCTs (UK FROST/Rangan et al. 2020) found MUA improves outcomes but is not superior to other interventions at 12 months; overall evidence sufficient to support net health benefit when clinical criteria met (AAOS includes MUA as an option). Woods et al. 2017 (730 patients, 792 shoulders) reported mean Oxford Shoulder Score improvement of 16 and identified higher repeat MUA risk with type-1 diabetes. Bidwai et al. 2016 reported significant OSS and ROM improvements in a 54-shoulder series.
Knee (Stiffness after Total Knee Arthroplasty - post-TKA)	Systematic review (Gu et al. 2018: 22 studies, 1488 patients) and observational studies (Randsborg et al. 2020) show consistent improvement in ROM post-MUA; ideal timing between 4–12 weeks post-op; overall complication rate ~1%; evidence sufficient to support net health benefit when criteria met.
Spine and other joints (spine, sacroiliac, pelvis, elbow, hip, wrist, hand, finger, ankle, TMJ, toe)	Evidence is limited to case series, observational studies, and nonrandomized comparisons; no high-quality RCTs for spinal MUA and insufficient evidence for net health benefit. Specific observational data: Spitler et al. 2018 (elbow) showed benefit when MUA performed within 3 months; TMJ evidence limited to a small prospective study (Foster 2000) with mixed results. Overall MUA for spine and most other joints considered investigational/insufficient evidence.
Selected study highlights	Gu et al. 2018 (systematic review, knee post-TKA): 22 studies, 1488 patients; improved ROM in most studies; ideal timing 4–12 weeks; complication rate <1%. Woods et al. 2017 (shoulder): 730 patients (792 shoulders); mean OSS improvement 16; higher repeat MUA risk in type‑1 diabetes. Spitler et al. 2018 (elbow): 45 patients; significant improvement when MUA performed within 3 months, little benefit after 3 months. Foster 2000 (TMJ): 55 patients; 15 improved, 6 partially improved; evidence limited and insufficient for definitive conclusions.

Definitions

Arthrofibrosis: A complication of injury or trauma where an excessive scar tissue response leads to 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 series of mobilization, stretching, and traction procedures performed while the individual is sedated (usually with general anesthesia or moderate sedation) intended to break up fibrous and scar tissue to relieve pain and improve range of motion.

Conservative management: Non-surgical treatments including physical therapy, steroid regimens, anti-inflammatory medications, activity modification, and other non-invasive measures.

Coding

Covered CPT codes for manipulation under anesthesia (listed for provider reporting)CPTCovered

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).

Place/Type of Servicemixed

PlaceOfService	Outpatient/Inpatient
TypeOfService	Surgical

No specific billing codes provided in this partmixed

No codes listed

Provider Actions & Documentation Requirements

Documentation Required

Document exclusion of other etiologies

Document in the medical record that other etiologies for the patient’s joint or spinal pain have been actively excluded. This should include relevant clinical history, focused physical examination findings, and appropriate imaging or diagnostic studies (for example, imaging to exclude significant glenohumeral osteoarthritis for shoulder cases or assessment of arthroplasty component position/size for post–TKA stiffness).

Documentation Required

Document failed conservative therapy

Document that a trial of conservative therapy has failed prior to performing MUA. For shoulder adhesive capsulitis this includes acetaminophen, NSAIDs, and/or oral corticosteroids for at least 3 weeks; a structured physical therapy/home exercise program for at least 6 weeks; and at least one intra‑articular corticosteroid injection. For knee (post‑TKA arthrofibrosis) this includes acetaminophen and/or NSAIDs for at least 3 weeks and a physical therapy/home exercise program for at least 6 weeks. Record dates, therapies tried, duration, response, and reason for escalation to MUA.

General Evidence-Based Conclusions by Indication

Practical guidance: Timing recommendations — for knee MUA after TKA, aim for the 4-12 week post-operative window; for post-traumatic elbow stiffness, higher likelihood of benefit when MUA is performed within 3 months of injury or surgery. Counseling points: document and discuss that comorbidities (especially diabetes and thyroid disorders) can reduce responsiveness and slow ROM recovery; ensure adequate trials of conservative care and set realistic expectations.

Revision History

January 2023policy_revised

Policy revised January 2023; revision noted in document header and history.

June 2024annual_review_and_renewal

Annual Review and Policy Renewed in June 2024 per policy history.

June 2025last_reviewLatest

Last review June 2025 with literature update through May 2025; no specific clinical policy statement changes detected in this part (material change flag: false).

Policy Summary

Payerblue cross blue shield - south dakota

PolicyManipulation under Anesthesia

Policy CodePolicy 08.01.20

Change TypeRevised (Jan 2023)Annual Review/Renewed (Jun 2024)

Effective DateApr 1, 2012

Last ReviewJun 1, 2025

Next Review DateN/A

Key ActionDocument clinical history, exam, appropriate imaging and failed conservative therapies with specified durations to support medical necessity prior to MUA.

SourceLink

On This Page

Prior Authorization

Verify benefit coverage

Verify member benefit coverage and any applicable limitations or exclusions before scheduling MUA. Benefits vary by contract and some plans may not cover certain indications (for example, TMJ benefits may not be available under all group plans). Confirm medical necessity only if benefits exist and there are no contract exclusions.

Prior Authorization

Prior approval

Prior approval: Not applicable in this policy section. Benefits determinations depend on contract language and member verification. Clinicians should still verify whether any health plan-specific prior authorization or notification requirements apply before proceeding.

Documentation Required

Inform patients with comorbidities about outcomes

Inform patients with comorbidities and risk factors about expected outcomes and potential risks. Counsel patients that evidence for MUA varies by joint and indication (stronger for adhesive capsulitis and post‑TKA stiffness; insufficient for spine, TMJ, toe, hip, elbow, wrist, hand, finger, and ankle), and discuss that outcomes may be less favorable or less certain in the presence of significant comorbid conditions.

Documentation Required

Conservative therapy trial before MUA

Ensure documentation shows that a conservative therapy trial was attempted and completed (see failed conservative therapy callout) before MUA is performed, except where clinically contraindicated. This includes conservative medications, formal physical therapy or home exercise programs, and appropriate use of corticosteroid injections where indicated.

Documentation Required

Timing documentation for knee/elbow MUA

For knee and elbow MUA after surgery, document timing relative to the index procedure. For post‑TKA arthrofibrosis, ideal timing is generally between 4 and 12 weeks post‑operatively when clinically appropriate; record the date of the index arthroplasty, onset of stiffness, dates of conservative management, and date of planned/performed MUA.

Denial Risk

Insufficient evidence indications

Document when indications are based on limited or insufficient evidence. For conditions where evidence is currently insufficient (spine, TMJ, toe MTPJ after hallux surgery, elbow, wrist, hand, finger, hip, ankle, and serial/serial-session use), include rationale for use, alternatives considered, discussion of investigational status with the patient, and why MUA is being considered despite limited data.