Modifiedsierra health and lifePolicy 2026T0515CC

Manipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Defines UnitedHealthcare Commercial and Individual Exchange coverage stance for Manipulation Under Anesthesia by joint/indication, specifying medically necessary indications (knee arthrofibrosis post-TKA, shoulder adhesive capsulitis with InterQual criteria) and listing joints/conditions considered unproven/not medically necessary; includes applicable CPT/HCPCS and ICD-10 reference codes and literature background.

Policy Summary

Payersierra health and life

PolicyManipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0515CC

Change TypeDefinitions and Clinical Evidence updated; prior version archived

Effective DateFeb 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, document that the case meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections.

2Proven/Covered Indications

9Unproven/Not Medically Necessary joints/conditions

9Reference procedure codes listed

Coverage Summary

Scope: This policy defines UnitedHealthcare Commercial and Individual Exchange coverage for Manipulation Under Anesthesia (MUA), specifying the conditions and joints for which MUA is considered medically necessary versus unproven/not medically necessary. It lists referenced CPT/HCPCS procedure codes and example ICD-10 diagnoses for documentation and billing, and notes use of InterQual criteria for certain shoulder cases.

Overview: MUA is considered proven and medically necessary for knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and for shoulder adhesive capsulitis (frozen shoulder) when the case meets the referenced InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria. The policy takes a mixed coverage stance: proven for these specific knee and qualifying shoulder indications but unproven/not medically necessary for other joints and conditions due to insufficient evidence.

Policy metadata and summary counts

Policy number2026T0515CC

Effective dateFebruary 1, 2026

Last reviewFebruary 1, 2026

StatusMODIFIED

Proven/Covered Indications (count)2

Listed Unproven/Not Medically Necessary Joints/Conditions (count)9

Reference CPT/HCPCS Procedure Codes Listed (count)9

Medical Necessity — Indications and Exclusions

Medically Necessary (Proven) Indications

Manipulation under anesthesia is proven and medically necessary when the following indication-specific criteria are met:

ANY of the following

Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Document diagnosis of arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication for MUA to support medical necessity.
Shoulder adhesive capsulitis: 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
Must meet InterQual criteria referenced in policy

Not Medically Necessary / Unproven Indications

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

Unproven / Not Medically Necessary Joints/Conditions

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 / Not Applicable

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

Exclusions

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

Provider Actions & Billing Instructions

Documentation Required

Shoulder InterQual criteria required

For shoulder adhesive capsulitis, documentation must demonstrate that the case meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria (InterQual referenced in policy).

Documentation Required

Knee arthrofibrosis indication documentation

Document diagnosis of arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication for MUA to support medical necessity.

M24.661 — Ankylosis, right knee
M24.662 — Ankylosis, left knee
M24.669 — Ankylosis, unspecified knee

Billing Rule

Reference procedure codes for claims

When billing for manipulation under anesthesia, use appropriate procedure CPT codes (e.g., 27570 for knee, 23700 for shoulder) or HCPCS D7830 as applicable; listing of codes in the policy is reference only and does not guarantee payment — member benefits govern.

27570 — Manipulation of knee joint under general anesthesia
23700 — Manipulation under anesthesia, shoulder joint
D7830 — Manipulation under anesthesia (HCPCS)

Relevant Codes (Reference)

Procedure CPT 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 / CPT-like code listedHCPCS

D7830

Manipulation under anesthesia

Diagnosis codes referenced (ICD-10 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.

Background & Evidence Summary

Background: Manipulation under anesthesia combines manual manipulation of a joint or the spine with administration of an anesthetic to treat motion-limiting scar tissue and adhesions; anesthetic approaches may include general anesthesia, mild sedation, or local anesthetic injection, and procedures are performed to break up fibrous adhesions and restore motion.

State of the evidence: High-quality evidence supports MUA for knee arthrofibrosis after total knee arthroplasty or other knee surgery/fracture, with systematic reviews, meta-analyses, observational studies, and a randomized trial demonstrating clinically meaningful improvements in range of motion (often greatest when performed earlier postoperatively) and functional scores. For shoulder adhesive capsulitis, MUA may be appropriate when InterQual clinical criteria are met (policy references the InterQual CP for shoulder). Evidence for MUA of the spine, temporomandibular joint, toe, ankle, hip, wrist, finger, pelvis and other non-knee joints is limited, inconsistent, or low quality, and these uses are considered unproven/not medically necessary by this policy. Relevant CPT/HCPCS and example ICD-10 codes are provided in the policy for reference.

Key Evidence Summary

Definitions, Codes, and Policy Scope