CurrentColorado Rocky Mountain Health PlansPolicy CS075.U

Manipulation Under Anesthesia – Community Plan Medical Policy

Defines clinical coverage rationale, applicable codes, definitions, and evidence for manipulation under anesthesia (MUA) across body joints for Colorado Rocky Mountain Health Plans Community Plan (policy CS075.U). Specifies which indications are medically necessary vs not medically necessary and lists excluded states where other state-specific policies apply.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyManipulation Under Anesthesia – Community Plan Medical Policy

Policy CodePolicy CS075.U

Change TypeDefinitions and supporting information updated; template changes

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, document and meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Definitions: Updated definition of 'Arthrofibrosis'.

Supporting Information: Updated clinical evidence and references to reflect current information.

Removed content/language pertaining to the state of Louisiana.

Template Update on 04/01/2026 removed content/language pertaining to the state of Louisiana.

Definitions updated on 03/01/2026 (definition of 'Arthrofibrosis' updated).

Content/language pertaining to the state of Louisiana was removed.

Previous policy version CS075.T was archived.

2Medically necessary indications

9Unproven/not medically necessary indications listed