RetiredCapital BluecrossPolicy MP 8.006

Manipulation Under Anesthesia (Retired 2/1/2025)

Defines medical necessity and investigational indications for manipulation under anesthesia (MUA) across joints, with specific covered indication for single-treatment shoulder MUA for adhesive capsulitis after failed conservative care; notes product/benefit variations and coding guidance. Policy is retired as of 2025-02-01.

Policy Summary

PayerCapital Bluecross

PolicyManipulation Under Anesthesia (Retired 2/1/2025)

Policy CodePolicy MP 8.006

Change TypeRetired / administrative updates

Effective Date

Next Review Date

Key ActionProvider must document failure of conservative medical management (medications ± articular injections, home exercise, and physical therapy) prior to MUA of the shoulder being considered medically necessary.

SourceLink

POLICY UPDATE CHANGES

Policy retired effective 06/12/2024 (document states Retirement 06/12/2024 and header indicates RETIRED 2/1/2025).

07/23/2018 Administrative update removed indications for knee manipulation and referenced Turning Point policy for knee MUA criteria effective 9/1/18.

CAC 04/26/2011 added investigational statement for serial treatment sessions and multiple body joints for chronic pain.

10/01/2019 administrative update added an unlisted code for shoulder.

1Covered Indications (shoulder adhesive capsulitis)

7Investigational Indications Listed

Coverage Summary

Policy MP 8.006: Manipulation Under Anesthesia (MUA) — RETIRED. This policy (MP 8.006) addresses Manipulation Under Anesthesia (MUA) and is marked as RETIRED (policy header shows RETIRED 2/1/2025; retirement noted 06/12/2024). The single covered indication retained in the policy is MUA of the shoulder for adhesive capsulitis (frozen shoulder) when conservative medical management has failed. The overall coverage stance is mixed: shoulder MUA for adhesive capsulitis may be medically necessary as a single treatment of an isolated joint after failed conservative care, while MUA for other indications (including spinal MUA, multiple joints, serial manipulations, and other joint sites) is considered investigational / not medically necessary. Operational and coding history notes administrative removal of knee indications (07/23/2018) with knee criteria referenced to Turning Point policy and an unlisted shoulder code added 10/01/2019.

Policy metadata

Policy numberMP 8.006

StatusRETIRED

Retirement noticesDocument notes retirement effective 06/12/2024 and header shows RETIRED 2/1/2025

Last review date2024-06-12

Primary covered indication count1 (shoulder adhesive capsulitis single-treatment)

Investigational indication count7 (listed investigational indications such as spinal, multiple joints, serial manipulations, other joint sites)

Medical Necessity and Investigational Criteria

Coding

Procedure codes - shoulder MUA considered medically necessary (examples listed)CPTCovered

23700	Manipulation under anesthesia, shoulder
unlisted	Unlisted code for shoulder (added 10/01/2019)

Procedure codes - MUA other than shoulder considered investigational / not coveredCPTNot Covered

21073	Manipulation under anesthesia (listed as investigational for MUA other than shoulder)
22505	Procedure code listed in investigational list
24300	Procedure code listed in investigational list
25259	Procedure code listed in investigational list
26340	Procedure code listed in investigational list
27275	Procedure code listed in investigational list
27860	Procedure code listed in investigational list

Diagnosis codes associated with covered indicationICD-10Covered

M75.00	Adhesive capsulitis of unspecified shoulder
M75.01	Adhesive capsulitis of right shoulder
M75.02	Adhesive capsulitis of left shoulder

Provider Actionables

Documentation Required

Document conservative management failure

Provider must document failure of conservative medical management (medications with or without articular injections, home exercise programs, and physical therapy) prior to considering manipulation under anesthesia (MUA) of the shoulder as medically necessary.

Denial Risk

Do not perform investigational indications

Claims for MUA for investigational indications — including spinal MUA, manipulation of multiple joints, serial manipulations (multiple sessions), and MUA of other joint sites for treatment of pain/contracture/stiffness/arthritis — are considered investigational and may be denied.

21073
22505

Background & Evidence

Background: Manipulation under anesthesia (MUA) is a procedure using anesthesia or sedation to reduce pain, spasm, and reflex guarding so therapists can perform mobilization, stretching, traction, and high-velocity thrusts to break up adhesions and improve range of motion; it is often performed with an anesthesiologist in attendance and may be combined with postoperative rehabilitation. Short definition: "Manipulation under anesthesia (MUA) — A procedure using anesthesia or sedation to reduce pain/spasm and permit mobilization, stretching, traction and high-velocity thrusts to break up adhesions and improve range of motion."

Typical use and limitations: MUA has historically been used for spinal and joint conditions and as an accepted treatment for isolated joint conditions (for example, adhesive capsulitis of the shoulder and previously for arthrofibrosis of the knee). The procedure may take approximately 15–20 minutes and is sometimes recommended in multiple consecutive sessions by some practitioners; care after MUA often includes 4–8 weeks of active rehabilitation. Evidence limitations: scientific evidence for spinal MUA and for multi-session or multi-joint MUA is very limited (mostly case series and nonrandomized studies), with no randomized controlled trials identified, and outcomes and safety data are insufficient to determine benefit for these investigational indications.

Key evidence points

Quality of evidenceInsufficient; evidence consists mostly of case series and nonrandomized studies; no randomized controlled trials identified

Guideline / referenceBCBSA Medical Policy Reference Manual 8.01.40 (May 2024) cited; additional cohort and case series studies referenced

Revision History

06/12/2024retirementLatest

Policy marked retired effective 06/12/2024; header later displays RETIRED 2/1/2025. (Material change)

07/23/2018administrative update

Administrative update removed indications for knee manipulation under anesthesia and redirected criteria to the Turning Point policy (effective reference for knee MUA criteria 9/1/18). (Material change)

04/26/2011clinical advisory committee clarification