Cigna Manipulation Under Anesthesia Coverage

Coverage Summary

Scope: This policy (Medical Coverage Policy: 0276, effective 2024-10-15, last reviewed 2026-03-15) defines medical necessity criteria, covered and not medically necessary indications, and applicable CPT codes for Manipulation Under Anesthesia (MUA).

Overview: Coverage is limited to a SINGLE treatment session of an isolated joint condition. A single-session MUA is considered medically necessary for specific indications — adhesive capsulitis, post‑traumatic/postoperative knee arthrofibrosis, reduction of certain fractures/dislocations, and chronic contractures — when conservative management has failed. Repeat or serial treatment sessions for the same bone/joint are subject to medical necessity review and are generally not medically necessary.

Coverage stance: The policy’s overall coverage stance is mixed: MUA is considered established/medically necessary for the listed indications when policy criteria are met, but MUA for other indications (including many pain conditions and serial MUAs) is considered not medically necessary.

Key thresholds and scope metrics

Allowed sessions per isolated joint1

Indications consideredAdhesive capsulitis; Knee arthrofibrosis; Fracture reduction; Dislocation reduction; Chronic contracture

CPT codes referencedMultiple (e.g., 23700, 27570, 23655, 27198, 24300, 25259, 26340, 27275, 27860, 28635)

Focused clinical policy change (2026-03-15)Removed spinal MUA policy statement; clarified non-covered indications and reinforced single-session limitation

Medical-Necessity Criteria

Medically Necessary (Single Treatment Session)

A single treatment of manipulation under anesthesia (MUA) is considered medically necessary when ANY of the following indications are met:

ANY of the following

Adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy/standard chiropractic treatment.
CPT: 23700
Post-traumatic or postoperative arthrofibrosis of the knee (e.g., total knee replacement, anterior cruciate ligament repair) when there is failure of conservative medical management, including exercise and physical therapy/standard chiropractic treatment.
CPT: 27570
Reduction of a displaced fracture (e.g., long bones).
(CPT codes depend on fracture site/procedure)

Coding

Primary Covered/Considered Medically Necessary CPT Codes (when policy criteria met)CPTCovered

23655	Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) (covered for adhesive capsulitis when conservative management failed)
27198	Closed treatment of posterior pelvic ring fracture(s)... with manipulation, requiring more than local anesthesia
24300	Manipulation, elbow, under anesthesia
24605	Treatment of closed elbow dislocation; requiring anesthesia
25259	Manipulation, wrist, under anesthesia
25690	Closed treatment of lunate dislocation, with manipulation
26641	Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675	Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia
26340	Manipulation, finger joint, under anesthesia, each joint

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Codes Specified as Not Medically Necessary (when used to report MUA for other conditions)CPTNot Covered

21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service
23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) (listed here to indicate not medically necessary when used for indications other than adhesive capsulitis)
24300	Manipulation, elbow, under anesthesia (not medically necessary for pain indications/other nonlisted indications)
25259	Manipulation, wrist, under anesthesia
26340	Manipulation, finger joint, under anesthesia, each joint
26989	Unlisted procedure, hands or fingers
27198	Closed treatment of posterior pelvic ring fracture(s)... with manipulation, requiring more than local anesthesia
27275	Manipulation, hip joint, requiring general anesthesia
27570	Manipulation of knee joint under general anesthesia
27860	Manipulation of ankle under general anesthesia

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Provider Actions

Documentation Required

Document failure of conservative management

Provider must document failure of conservative medical management for indications where MUA is considered medically necessary (adhesive capsulitis, arthrofibrosis of the knee, chronic contracture). Document prior conservative therapies attempted, such as medications with or without articular injections, home exercise programs, physical therapy or standard chiropractic treatment, and bracing/splinting where applicable.

Examples to document: medications ± joint injections
Home exercise program adherence
Physical therapy or standard chiropractic treatment trials
Bracing or splinting where applicable

Prior Authorization

Medical necessity review for repeat/serial sessions

Background, Evidence & Definitions

Background: Manipulation under anesthesia involves manipulation and stretching performed while an individual receives anesthesia to reduce pain and improve range of motion. The procedure is established and considered effective for specific conditions including adhesive capsulitis (frozen shoulder), arthrofibrosis of the knee, selected fractures and dislocations, and chronic contractures when conservative therapy fails. For fracture/dislocation contexts, MUA is often incidental to the base surgical repair or arthroscopy.

Limits of evidence: The policy and supporting literature note limited peer-reviewed evidence for MUA when used to manage acute or chronic pain conditions or for many major joints (e.g., hip, ankle, elbow, wrist, temporomandibular joint). Data supporting serial or repeat MUA sessions are lacking; the policy limits coverage to a single session and states that serial treatments are not in accordance with generally accepted medical practice and are therefore not medically necessary.

Evidence / Finding	Detail
MUA considered medically necessary for adhesive capsulitis when conservative management fails
Single treatment session (repeat/serial sessions not routinely covered)
MUA considered medically necessary for post-traumatic/postoperative knee arthrofibrosis when conservative management fails
Knee arthrofibrosis: informational ROM threshold < 90° following surgery/trauma despite physical therapy
MUA considered established/effective for some fractures and dislocations; typically incidental to base surgical procedure
MUA considered medically necessary for chronic contracture of extremity joints when conservative management fails
Limited evidence for MUA in management of pain conditions or for many major joints; serial/repeat MUAs lack supportive evidence
Policy changes: Focused review 3/15/2026 removed spinal MUA statement and clarified non-covered indications; annual reviews 9/15/2025 and 10/15/2024 had no clinical changes

Glossary:

• Manipulation Under Anesthesia (MUA): Manipulation and stretching procedures performed while the individual receives anesthesia (e.g., conscious sedation, general anesthesia) to reduce pain and improve range of motion.

• Serial treatment sessions: Treatments of the same bone/joint provided subsequently over a period of time; per policy these are considered not medically necessary and are subject to review.

• MUJA (Manipulation under joint anesthesia/analgesia): MUA accompanied by fluoroscopically guided intra‑articular injections with corticosteroid agents.

Revision History

2026-03-15focused_review_removedLatest

Focused review removed policy statement for spinal manipulation under anesthesia.

2026-03-15focused_review_clarifiedLatest

Focused review clarified non-covered indications and reinforced the limitation to a single treatment session (serial/repeat sessions not medically necessary).

2025-09-15administrative_annual_review

Not Medically Necessary (Other Indications / Pain Management / Repeat or Serial Sessions)

MUA for any other indication, including treatment of acute or chronic pain conditions involving one or more of the following joints, is considered not medically necessary. Serial or repeat sessions are not covered as noted below.

ALL of the following

Affected joints (examples of CPT codes)
- Ankle
  CPT: 27860
- Elbow
  CPT: 24300
- Finger/Thumb
  CPT: 26340, 26989
- Hip
  CPT: 27275
- Knee (other than post‑traumatic/postoperative arthrofibrosis)
  CPT: 27570
- Pelvis/Sacroiliac
  CPT: 27198
- Shoulder (other than adhesive capsulitis)
  CPT: 23700
- Temporomandibular (TMJ)
  CPT: 21073
- Toe
  CPT: 28899
- Wrist
  CPT: 25259
Repeat or serial treatment sessions: Repeat treatment sessions involving a previously treated bone or joint are subject to medical necessity review. Serial treatment sessions (i.e., treatments of the same bone/joint provided subsequently over a period of time) are not in accordance with generally accepted standards of medical practice and are therefore not medically necessary.
Coverage is limited to a SINGLE treatment session of an isolated joint condition.

Joint-Specific "Considered Medically Necessary" Statements

Joint-specific statements: The following joint procedures are considered medically necessary when the above applicable criteria are met (i.e., when criteria in the Medically Necessary section are satisfied). CPT examples/descriptions are shown for each joint.