CurrentColorado Rocky Mountain Health PlansPolicy 2026T0515CC

Manipulation Under Anesthesia – Commercial and Individual Exchange Medical Policyopen_in_new

Defines UnitedHealthcare Commercial and Individual Exchange medical policy coverage for manipulation under anesthesia (MUA) by joint/site, specifying medically necessary indications (knee and shoulder) and listing joints/conditions considered unproven/not medically necessary; includes applicable CPT/HCPCS/ICD-10 codes, definitions, clinical evidence summary, and policy revision history.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyManipulation Under Anesthesia – Commercial and Individual Exchange Medical Policyopen_in_new

Policy CodePolicy 2026T0515CC

Change TypeDefinitions revised; Clinical Evidence and References updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference InterQual CP: Procedures, Manipulation Under Anesthesia to establish medical necessity for shoulder MUA.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis'.

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version 2026T0515BB.

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

Archived previous policy version 2026T0515BB.

2Sites with explicit 'medically necessary' coverage (knee, shoulder)

9Sites listed as unproven/not medically necessary

Coverage Summary

Policy 2026T0515CC (Effective: 02/01/2026; Last review: 02/01/2026) defines UnitedHealthcare Commercial and Individual Exchange coverage for Manipulation Under Anesthesia (MUA). The policy status is CURRENT. MUA is considered medically necessary for the knee to treat arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and for the shoulder to treat adhesive capsulitis when InterQual clinical coverage criteria are met. Use of MUA for other joints/conditions is characterized as unproven and not medically necessary. Definitions were updated on 02/01/2026. The brief highlights include: 2 explicitly covered sites (knee, shoulder), 9 sites listed as unproven/not medically necessary, and 11 example CPT/HCPCS codes referenced.

Surface quick facts

Policy number2026T0515CC

PayerColorado Rocky Mountain Health Plans

Effective date2026-02-01

Last review2026-02-01

StatusCURRENT

Key sites coveredKnee (arthrofibrosis after TKA, knee surgery, or fracture); Shoulder (adhesive capsulitis when InterQual criteria met)

Major sites not coveredAnkle; Finger; Hip; Pelvis; Spine; Temporomandibular joint (TMJ); Toe; Wrist; Knee for indications other than post‑TKA arthrofibrosis

Medical Necessity / Coverage Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

Medically Necessary indications

Knee indication: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder indication: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met; for medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder
Providers must reference InterQual criteria to establish medical necessity for shoulder MUA.

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:

Coding (Referenced Codes)

Referenced CPT / Procedure CodesCPT

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), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (i.e., general anesthesia, moderate sedation, spinal/epidural)
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)

Referenced HCPCS / ADA CodeHCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 Diagnosis Codes (examples provided)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

Documentation Required

Refer to InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis, reference the InterQual CP: Procedures, Manipulation Under Anesthesia — providers must use InterQual clinical coverage criteria to establish medical necessity for shoulder MUA.

Documentation Required

Reference member-specific benefit plan

Before applying this policy, check the member-specific benefit plan document and any applicable federal or state mandates because member-specific terms may differ and govern in case of conflict.

Background & Clinical Evidence

Manipulation under anesthesia combines manual joint or spinal manipulation with an anesthetic (general, sedation, or local) to overcome pain, spasm, and muscle guarding, with the goal of breaking fibrous adhesions and improving range of motion. The evidence base is strongest for the knee—particularly for postoperative arthrofibrosis after total knee arthroplasty—with multiple systematic reviews, cohort studies, and randomized trials reporting clinically meaningful range-of-motion gains, often greater when performed earlier. Evidence also supports certain shoulder adhesive capsulitis cases when InterQual criteria are met. For many other joints (spine, TMJ, ankle, toe, hip, finger, wrist, pelvis), the evidence is limited, low quality, or inconsistent and does not reliably support MUA as effective.

Evidence Item	Summary
Knee - systematic review/meta-analysis (Patel et al. 2025)	Identified risk factors for postoperative stiffness requiring MUA after primary TKA; findings inform preoperative planning (younger age, Black race, smoking, lower ASA score, prior knee surgery).
Knee - randomized trial (Abdel et al. 2024)	MUA produced a mean immediate ROM improvement of 46°; no difference in ROM at 6 weeks and 1 year with adjuvant anti-inflammatory medications.
Knee - multiple systematic reviews and cohort studies (2018-2025)	Generally show ROM improvements after MUA for postoperative knee arthrofibrosis, with better outcomes when performed earlier; evidence heterogeneous in quality.
Spine / TMJ / Toe / Other joints	Evidence limited, low quality, and inconsistent; MUA not consistently supported as effective for many non-knee/shoulder indications.
Recent publications cited	Selected references include J Arthroplasty 2024 Feb;39(2):368-373 and J Arthroplasty 2025 Sep;40(9S1):S535-S544.

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 definition of 'Arthrofibrosis' was updated in the policy on 02/01/2026 (revised wording reflected in the policy's Definitions section).

Revision History

02/01/2026revisedLatest

Policy History/Revision Information entry dated 02/01/2026 — Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version 2026T0515BB. (Policy History/Revision Information updated)

02/01/2026revised

Definitions section revised to update the meaning of Arthrofibrosis. (Definitions section revised) — MATERIAL CHANGE

02/01/2026revised