CurrentUnitedHealthcarePolicy CS075KS.02

Manipulation Under Anesthesia (for Kansas Only)

UnitedHealthcare Community Plan medical policy applicable only to Kansas members governing coverage of manipulation under anesthesia (MUA) procedures, specifying covered indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual), listing noncovered/unproven indications, applicable CPT/HCPCS and ICD-10 codes for reference, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kansas Only)

Policy CodePolicy CS075KS.02

Change TypeRevised definition and supporting information

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to establish medical necessity.

POLICY UPDATE CHANGES

Updated definition and supporting information effective 03/01/2026.

2Covered Indications (explicit)

9Not‑Medically‑Necessary Joint Sites

10Procedure/HCPCS/CPT codes listed

Coverage Summary

Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual joint manipulation with anesthesia to overcome pain, spasm, and break adhesions. This Kansas-only UnitedHealthcare Community Plan policy addresses MUA coverage with a mixed coverage stance: 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 (frozen shoulder) when the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria are met. The policy lists other joint sites (spine, temporomandibular joint, toe, ankle, hip, finger, wrist, pelvis, and knee indications other than post-TKA/surgery/fracture arthrofibrosis) as unproven/not medically necessary due to insufficient evidence. The policy includes applicable CPT/HCPCS and ICD-10 reference codes and documents an updated arthrofibrosis definition and clinical evidence effective 03/01/2026.

Key policy stats and dates

Covered Indications2 (Knee arthrofibrosis post‑TKA/surgery/fracture; Shoulder adhesive capsulitis per InterQual)

Not‑Medically‑Necessary Joint Sites9 (Ankle; Finger; Hip; Knee - other indications; Pelvis; Spine; Temporomandibular joint; Toe; Wrist)

Procedure / HCPCS / CPT codes listed10 (21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830)

Effective dateMarch 1, 2026

Last reviewMarch 1, 2026

Policy numberCS075KS.02

Subject (policy title)Manipulation Under Anesthesia (Kansas-only)

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

ANY of the following

Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
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
Provider must reference InterQual criteria for specific clinical requirements

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:

ANY 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 Applicable

This policy does not apply to the following:

ANY 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

Applicable Codes

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 / D code for Manipulation under anesthesiaHCPCS

D7830

Manipulation under anesthesia

Relevant ICD-10 diagnosis codes (reference list)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

Reference InterQual for shoulder MUA medical necessity

For shoulder adhesive capsulitis (frozen shoulder), providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to establish medical necessity. Refer to InterQual for the specific clinical coverage requirements when requesting or documenting shoulder MUA.

Policy directs reviewers to InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity determination
Applicable when treating adhesive capsulitis of the shoulder

Billing Rule

Use referenced procedure and HCPCS codes for claims

When billing for manipulation under anesthesia, claims should reference the appropriate CPT procedure code(s) or HCPCS D7830 as listed in the policy's Applicable Codes section. Inclusion of a code in the policy is provided for reference only and does not guarantee reimbursement or payment.

21073
22505
23700
25259
26340
27198
27275
27570
27860
D7830

Background & Evidence

MUA is defined as a noninvasive procedure that combines manual manipulation of a joint or the spine with an anesthetic to enable manipulation (e.g., to break fibrous adhesions and scar tissue) in persons unable to tolerate manual procedures due to pain, spasm, contracture, or guarding. The evidence base is strongest for the knee—particularly for arthrofibrosis after TKA, knee surgery, or fracture—where systematic reviews, retrospective series, and randomized trials report improvements in range of motion and functional scores. Evidence for the shoulder is selective and governed by InterQual clinical criteria for adhesive capsulitis. For other joints (spine, TMJ, toe, ankle, hip, finger, wrist, pelvis) the available studies are limited, inconsistent, and of lower methodological quality, and the policy considers MUA for those indications unproven or not medically necessary.

Multiple systematic reviews, retrospective studies, and randomized trials (2018–2025) were reviewed. Systematic reviews and meta-analyses and recent randomized trials for postoperative knee stiffness after TKA show consistent improvements in range of motion after MUA and identify risk factors and timing effects; randomized and multicenter data (e.g., Abdel et al., 2024; Patel et al., 2025; Walsh et al., 2024) support efficacy in the knee. For other joints, the evidence is limited, heterogeneous, and of lower quality, yielding insufficient support for routine coverage.

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).

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kansas Only)

Policy CodePolicy CS075KS.02

Change TypeRevised definition and supporting information

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to establish medical necessity.

On This Page

OpenPayer

Manipulation Under Anesthesia (for Kansas Only)

Coverage Summary

Medical-Necessity Criteria

Applicable Codes

Provider Actions

Background & Evidence

Revision History