CurrentColorado Rocky Mountain Health PlansPolicy 2026T0515CC

Manipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Defines UnitedHealthcare Commercial and Individual Exchange coverage for Manipulation Under Anesthesia (MUA), specifying covered indications (knee arthrofibrosis post-TKA, shoulder adhesive capsulitis per InterQual), lists noncovered/unproven joints/conditions, applicable CPT/HCPCS and ICD-10 codes, definitions, evidence summary, and revision history. Part 1 of 2.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyManipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0515CC

Change TypeDefinitions, Clinical Evidence, References updated; prior version archived

Effective DateFeb 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis coverage, providers must meet InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria; refer to InterQual for specific medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections to reflect the most current information.

Updated definition of 'Arthrofibrosis'.

Updated Supporting Information, Clinical Evidence, and References sections to reflect the most current information.

Archived previous policy version 2026T0515BB.

2Specifically Covered Joints / Indications Listed

9Unproven / Not Medically Necessary Joints

10+Evidence Studies/Reviews Cited

Coverage Summary

This policy addresses Manipulation Under Anesthesia (MUA). It applies to UnitedHealthcare Commercial and Individual Exchange plans and specifically covers MUA for knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and for shoulder adhesive capsulitis (frozen shoulder) when InterQual clinical criteria are met. Policy Number: 2026T0515CC. Effective Date: February 1, 2026.

Key Facts — Manipulation Under Anesthesia

Specifically Covered Joints / Indications Listed2

Joints/Conditions Listed as Unproven/Not Medically Necessary9

Referenced Evidence Studies/Reviews Cited10+

Policy History Items3

Effective Date2026-02-01

Policy Number2026T0515CC

Medical-Necessity Criteria

Medically Necessary (Covered)

Manipulation under anesthesia is proven and medically necessary for:

Knee - Arthrofibrosis following TKA/surgery/fracture: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met
Refer to InterQual criteria for specific clinical coverage requirements (For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder).

Not Medically Necessary / Unproven

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

Exclusions (Where This Policy Does Not Apply)

Exclusions (Policy Does Not Apply To)

Finger manipulation after Xiaflex: 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

Provider Actions & Operational Guidance

Documentation Required

Shoulder MUA requires InterQual criteria

For shoulder adhesive capsulitis (frozen shoulder), providers must meet the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria. Refer to InterQual for the specific medical necessity requirements prior to performing Shoulder MUA.

Documentation Required

Member-specific benefit verification / Verify member-specific benefits and mandates

Before using this policy to determine coverage, verify the member-specific benefit plan document and any applicable federal or state mandates. Benefit coverage is determined by the member's specific plan and those documents govern in the event of a conflict with this policy.

Member-specific benefit verification
Verify member-specific benefits and mandates

Coding

Procedure Codes (reference list)CPT

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).

HCPCS / MiscHCPCS

D7830

Manipulation under anesthesia

Diagnosis Codes (examples related to covered indications)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.

policy version archivedmixed

2026T0515BB

previous policy version archived

Background, Definitions & Evidence Summary

Manipulation under anesthesia combines manual joint manipulation with anesthetic agents to overcome pain, spasm, and guarding to break adhesions and improve range of motion. Evidence in the policy supports MUA for knee arthrofibrosis post‑TKA and for shoulder adhesive capsulitis when InterQual criteria are satisfied; for other joints and indications the policy notes a lack of high‑quality evidence supporting MUA. The policy history documents an updated definition of Arthrofibrosis effective 02/01/2026.

Definitions:

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).

Note: The policy indicates that the definition of Arthrofibrosis was updated in this policy (see Policy History/Part 1).

Study/Source	Key Finding
Abdel et al. 2024 (randomized trial)	MUA produced an immediate mean ROM improvement of 46° (from 72° to 118°); no difference between groups with adjunct anti‑inflammatory therapy at 6 weeks or 1 year.
Patel et al. 2025 (systematic review/meta‑analysis)	Identified risk factors for post‑TKA stiffness requiring MUA (younger age, Black race, smoking, lower ASA score, prior knee procedure) from 53 studies involving >2.9 million individuals.
Walsh et al. 2024 (retrospective single‑institution study)	MUA (vs aLOA+MUA) performed earlier post‑op, had lower revision rates and greater mean flexion gains; successful MUAs gained ~33° flexion; failures had minimal gains.
Multiple systematic reviews and cohort studies (e.g., Haffar 2022; Gu 2018; Fackler 2022)	Overall evidence supports efficacy of MUA for post‑TKA arthrofibrosis with ROM gains (commonly >20–40°); quality of evidence variable and limited for other joints.
Selected recent references (J Arthroplasty, J Arthroplasty reviews 2024–2025)	Contemporary publications report MUA outcomes, timing considerations (early vs delayed), and risk factors; evidence cited in policy references list.

Policy History / Revisions

2026-02-01Policy Revision - Definitions and Supporting Information UpdatedLatest

Updated definition of 'Arthrofibrosis'; updated Supporting Information, Clinical Evidence, and References sections to reflect most current information.

2026-02-01Policy Revision - Version ArchivedLatest

Archived previous policy version 2026T0515BB.

2026-02-01Document Effective Date

Instructions for Use / Coverage Determination Guidance

Instructions for Use

Coverage determinations guidance and precedence:

Member-specific plan governs: This policy provides assistance in interpreting UnitedHealthcare standard benefit plans; member-specific benefit plan documents may differ and govern in the event of conflict
Check mandates: Before using this policy, check the member-specific benefit plan document and any applicable federal or state mandates
MAO discretion: In the absence of a Medicare NCD/LCD or other Medicare coverage guidance, a Medicare Advantage Organization may create its own coverage determinations using objective evidence-based rationale