CurrentColorado Rocky Mountain Health PlansPolicy CS075OH.D

Manipulation Under Anesthesia (for Ohio Only)

State-specific UnitedHealthcare medical policy for manipulation under anesthesia (MUA) applicable only to Ohio members; defines covered indications (knee arthrofibrosis after TKA/ knee surgery/ fracture and shoulder adhesive capsulitis per InterQual), lists not medically necessary indications, applicable CPT/CPT-like codes and diagnosis codes, definitions, evidence summary, and policy history.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyManipulation Under Anesthesia (for Ohio Only)

Policy CodePolicy CS075OH.D

Change TypeRevised (definitions and supporting information)

Effective DateApr 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, provider must meet InterQual CP criteria and document InterQual criteria adherence in the medical record.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075OH.C

2Covered Indications (explicit)

9Not Medically Necessary items

11Procedure codes referenced

Coverage Summary

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This is a state-specific UnitedHealthcare medical policy for Manipulation Under Anesthesia (MUA) applicable only to Ohio members. It defines covered indications as knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and shoulder adhesive capsulitis (frozen shoulder) when InterQual clinical coverage criteria are met, and it lists other joints/conditions for which MUA is considered not medically necessary / unproven. The policy also identifies applicable CPT/CPT-like and diagnosis codes, provides definitions (including Arthrofibrosis), and documents policy history and state-specific applicability.

Medical Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary when ANY of the following specific joint/condition criteria are met:

ANY of the following

Knee - Arthrofibrosis following TKA/knee surgery/fracture: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis per InterQual: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met per InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder
Refer to InterQual CP for detailed clinical coverage criteria

Not Medically Necessary / Unproven

Manipulation under anesthesia is unproven and not medically necessary for all other conditions (whether single or serial manipulations), including but not limited to:

Not medically necessary / Unproven indications

Ankle
Finger
Hip joint or adhesive capsulitis of the hip
Knee - other: Knee joint - any condition other than for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Pelvis
Spine

Exclusions / Non-applicable Scenarios

This policy does not apply to the following procedures or scenarios:

Finger after Xiaflex injection: Manipulation of the finger on the day following the injection of collagenase clostridium histolyticum (Xiaflex®) to treat Dupuytren contracture
Closed reduction exclusion: Closed reduction of a fracture or joint dislocation unless specified
Elbow arthrofibrosis: Elbow joint for Arthrofibrosis following elbow surgery or fracture

Coding

Procedure / CPT and CPT-like codes referencedmixed

21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)
22505	Manipulation of spine requiring anesthesia, any region
23700	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
25259	Manipulation, wrist, under anesthesia
26340	Manipulation, finger joint, under anesthesia, each joint
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 (includes application of traction or other fixation devices)
27860	Manipulation of ankle under general anesthesia (includes application of traction or another fixation apparatus)
D7830	Manipulation under anesthesia (D-code)

Diagnosis codes referenced (examples)ICD-10

M24.661	Ankylosis, right knee
M24.662	Ankylosis, left knee
M24.669	Ankylosis, unspecified knee
M24.611	Ankylosis, right shoulder
M24.612	Ankylosis, left shoulder
M24.619	Ankylosis, unspecified shoulder
M75.00	Adhesive capsulitis of unspecified shoulder
M75.01	Adhesive capsulitis of right shoulder
M75.02	Adhesive capsulitis of left shoulder

Provider Actions

Documentation Required

Use InterQual for shoulder MUA criteria

For shoulder adhesive capsulitis, follow the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria and document in the medical record that the InterQual criteria were met. Adherence to InterQual should be clearly noted in the patient chart and supporting documentation (clinical findings, prior treatments, and decision rationale) retained in the medical record.

Document that InterQual criteria were met in the medical record.

Prior Authorization

State-specific medical necessity evaluation

Requests for services described as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Prior authorization may be required per plan rules and state regulations when state-specific medical necessity evaluation is applied.

Billing Rule

CPT/CPT-like code usage

Report the CPT/CPT-like or D-code that accurately describes the manipulation under anesthesia procedure performed and ensure the diagnosis supports a covered indication (knee arthrofibrosis after TKA/surgery/fracture or shoulder adhesive capsulitis per InterQual).

27570
23700
D7830
Ensure diagnosis supports the covered indication (e.g., knee arthrofibrosis after TKA/surgery/fracture or shoulder adhesive capsulitis per InterQual).

Background & Evidence Summary

Manipulation under anesthesia is a noninvasive procedure that combines manual joint manipulation with an anesthetic to address pain, spasm, muscle contractures, or scar-related motion restriction. The policy states MUA is proven and medically necessary for the knee joint for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and for the shoulder joint for adhesive capsulitis (frozen shoulder) when InterQual criteria are met. The supporting clinical evidence cited includes multiple systematic reviews, cohort studies, and randomized trials showing clinically significant immediate and sustained range-of-motion gains after knee MUA when performed for post-TKA arthrofibrosis (including meta-analyses and randomized data demonstrating immediate ROM improvements and overall efficacy), while evidence for MUA in other joints (spine, TMJ, toe, ankle, hip, wrist, finger, pelvis) is limited, inconsistent, and lacking high-quality studies, leading the policy to consider MUA for those joints unproven and not medically necessary.

Study / Source	Key findings
RCT - Knee MUA (Abdel et al., 2024)
Immediate ROM improved mean 46° (from 72° to 118°) immediately following MUA; no difference between treatment (pre-MUA IV dexamethasone + 14 days celecoxib) and control groups at 6 weeks (101° vs 99°, p=0.35) or 1 year (108° vs 108°, p=0.98)
Systematic review - ACLR (Hopper et al., 2024)
Among 333,876 ACLRs, 4,842 subsequent MUA/LOA (1.45%); identified risk factors including female sex, older age, earlier surgery, anticoagulant use (non-aspirin), and concomitant meniscal repair
Systematic review/meta-analyses and cohort studies - post-TKA stiffness (multiple sources)
Multiple studies and reviews report MUA efficacy for postoperative knee arthrofibrosis with typical flexion gains in successful cases (~27°–33°), average ROM increases reported (e.g., ~21° average in one review), better outcomes when performed early, and most studies show clinically significant ROM improvement after MUA; limitations include nonrandomized designs and heterogeneity

Arthrofibrosis: A complication of injury or trauma in which 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 (International Pain Foundation).