CurrentColorado Rocky Mountain Health PlansPolicy CS075OH.D

Manipulation Under Anesthesia (for Ohio Only)

Medical policy applying only to Ohio for coverage of manipulation under anesthesia (MUA) procedures; defines conditions considered proven/medically necessary vs unproven/not medically necessary, references InterQual criteria for shoulder, lists applicable CPT/CPT-like and ICD-10 codes, and includes supporting evidence and exclusions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyManipulation Under Anesthesia (for Ohio Only)

Policy CodePolicy CS075OH.D

Change TypeRevised definition and evidence (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder and supply required documentation for medical necessity.

SourceLink

POLICY UPDATE CHANGES

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

2Indications considered proven/medically necessary

9Joints listed as unproven/not medically necessary

1State-specific (Ohio only)

Coverage Summary

MUA is considered 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 the specified InterQual clinical criteria are met. All other joint indications listed in the policy are considered unproven and not medically necessary.

Medical Necessity / Coverage Criteria

Medically Necessary (Proven) Indications

Covered when ALL of the following are met:

ONE of the following joint indications

Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Clinical necessity for knee arthrofibrosis following specified triggers
Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met
Medical necessity clinical coverage criteria to be determined by InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder

Not Medically Necessary (Unproven) Indications

Manipulation under anesthesia is unproven and not medically necessary for all other conditions, including but not limited to:

ALL of the following

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

Exclusions / Not Covered Scenarios

This policy does not apply to the following procedures/contexts:

ALL of the following

Manipulation of the finger on the day following the injection of collagenase clostridium histolyticum (Xiaflex) to treat Dupuytren contracture
Closed reduction of a fracture or joint dislocation unless specified
Elbow joint for Arthrofibrosis following elbow surgery or fracture (policy does not apply)

Coding

Referenced CPT / Procedure Codes (for reference only)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)

CDT / D codemixed

D7830

Manipulation under anesthesia

Referenced ICD-10 Diagnosis Codes (example codes 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 / Prior Authorization & Documentation

Documentation Required

Use InterQual for Shoulder MUA Criteria

For shoulder adhesive capsulitis, medical necessity determinations must reference the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder. Providers should supply the documentation required by the InterQual criteria to support medical necessity.

Documentation Required

Apply Ohio Administrative Code for Unproven Services

Requests for services listed as unproven or for which coverage or quantity limits apply will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Providers must document compliance with the OAC requirements when submitting requests for these services.

Background and Evidence

Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual manipulation of a joint or the spine with an anesthetic agent to help break adhesions and improve range of motion. Anesthetic approaches described include general anesthesia, mild sedation, local injection of an anesthetic to the affected area, oral medications such as muscle relaxants, or inhaled anesthetics; procedures can be performed under general anesthesia, mild sedation, or local injection.

The quality of evidence for MUA varies by joint. The strongest evidence and coverage rationale support MUA for knee arthrofibrosis after total knee arthroplasty (TKA), with multiple systematic reviews, observational studies, and randomized trials reporting clinically meaningful immediate and follow-up range-of-motion gains. Randomized and comparative studies report substantial immediate ROM improvement after MUA for post-TKA stiffness and systematic reviews/meta-analyses identify risk factors and outcomes supporting its use when nonoperative care fails.

Evidence for other joints is limited or inconsistent; for example, spinal and other joint indications have small studies, methodological limitations, or insufficient high-quality data, and are considered unproven due to inadequate evidence of efficacy.

Selected Evidence Summary

Patel et al. (2025) systematic review size53 studies; 2,931,517 individuals

Abdel et al. (2024) randomized trialMulticenter RCT, 124 participants; immediate mean ROM gain 46°

Spine evidence summaryMultiple reviews and small studies show insufficient evidence and methodological limitations for spinal MUA effectiveness

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).