CurrentUnitedHealthcarePolicy CSO75.T

Manipulation Under Anesthesia

Defines UnitedHealthcare's medical necessity and noncoverage positions for manipulation under anesthesia (MUA) by joint/site, references InterQual criteria for shoulder, lists applicable CPT/HCPCS and ICD-10 codes, summarizes clinical evidence, and states state-specific applicability exclusions.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia

Policy CodePolicy CSO75.T

Change TypeClinical evidence & application updates

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionFor shoulder MUA use the InterQual Procedures: Manipulation Under Anesthesia, Shoulder criteria; document knee MUA as arthrofibrosis after TKA, knee surgery, or fracture; claims for other joints/indications may be denied.

POLICY UPDATE CHANGES

Application section updated to indicate the policy does not apply to Idaho and Kansas and to refer to state-specific policy versions.

Supporting information updated in Clinical Evidence and References sections to reflect the most current information.

2Covered Joint Indications (shoulder, knee arthrofibrosis)

9Listed Not-Covered Joints/Conditions

1InterQual referenced for shoulder

Coverage Summary

Manipulation Under Anesthesia (MUA) is a non‑invasive procedure that combines manual manipulation of a joint (or the spine) with an anesthetic agent to permit breaking adhesions in patients who cannot tolerate manipulation because of pain, spasm, contracture, or guarding. Anesthetic approaches may include general anesthesia, mild sedation, or local injection/other anesthetic medications. (Policy: CSO75.T, effective 2025-04-01.)

Evidence for MUA varies by joint. The policy identifies shoulder adhesive capsulitis (frozen shoulder) and knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the joints/sites with the strongest support and deemed medically necessary when criteria are met (shoulder per InterQual®; knee for postoperative arthrofibrosis). For many other joints (spine, TMJ, toe, ankle, finger, hip, pelvis, wrist and knee indications other than specified arthrofibrosis), the evidence is described as insufficient or inconsistent and the policy considers MUA unproven or not medically necessary for those uses.

This Medical Policy (CSO75.T) includes a state‑specific applicability note: the policy does not apply to certain states; Idaho and Kansas are specifically listed as exclusions and users are instructed to refer to the applicable state‑specific policy versions. The overall coverage stance in this policy is mixed (some joint indications medically necessary, others unproven/not medically necessary).

Policy dates and quick facts

Effective DateApril 1, 2025

Last ReviewJune 1, 2025

Policy NumberCSO75.T

Covered Joint Indications (count)2

Listed Not‑Covered Joints/Conditions (count)9

InterQual reference for shoulderYes (InterQual referenced)

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia (MUA) is proven and medically necessary for:

Medically Necessary criteria

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
Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture

Not Medically Necessary / Unproven

MUA is unproven and not medically necessary for all other conditions (whether for single or serial manipulations); including but not limited to the following; due to insufficient evidence of efficacy:

Not medically necessary / unproven joints/conditions

Ankle
Finger
Knee other indications: Knee joint any condition other than for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Hip (joint or adhesive capsulitis of the hip)
Pelvis
Spine
Toe

Coding

CPT / Procedure codes referencedCPT

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 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)

HCPCS codes referencedHCPCS

D7830

Manipulation under anesthesia

ICD-10 diagnosis codes referencedICD-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

Use InterQual criteria for shoulder MUA documentation

For shoulder MUA for adhesive capsulitis, providers must meet the medical necessity clinical coverage criteria as defined in the InterQual® Procedures: Manipulation Under Anesthesia, Shoulder (link referenced in policy).

InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder (see policy link)

Documentation Required

Knee MUA indication documentation

For knee MUA to be covered, documentation must support arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.

Documentation must indicate arthrofibrosis as a complication following total knee arthroplasty (TKA), prior knee surgery, or fracture

Denial Risk

Claims for MUA for non-covered joints/indications may be denied

MUA performed for conditions listed as unproven/not medically necessary (e.g., ankle, finger, hip, pelvis, spine, toe, TMJ, wrist, or knee indications other than specified arthrofibrosis) are considered unproven and not medically necessary and subject to denial.

Examples of non-covered joints/indications: ankle, finger, hip, pelvis, spine, toe, temporomandibular joint (TMJ), wrist, and knee indications other than arthrofibrosis following TKA/knee surgery/fracture

Background & Evidence Summary

Manipulation under anesthesia (MUA) combines manual manipulation of a joint or the spine with an anesthetic to allow providers to use specific manipulative techniques, passive stretches, and kinesthetic maneuvers to break fibrous adhesions and scar tissue around the joint and surrounding tissues in individuals unable to tolerate manipulation because of pain, spasm, or guarding. Anesthetic options described in the policy include intravenous general anesthesia, mild sedation, injection of a local anesthetic to the affected area, oral medications such as muscle relaxants, inhaled anesthetics, or other anesthetic medication therapies; procedures can be performed under general anesthesia, mild sedation, or local injection.

The policy states that evidence varies by joint. It identifies MUA as proven and medically necessary for the shoulder for adhesive capsulitis (when InterQual® criteria are met) and for the knee for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture. For other joints and indications—including but not limited to ankle, finger, hip, pelvis, spine, toe, temporomandibular joint (TMJ), and wrist—MUA is described as unproven and not medically necessary due to insufficient evidence of efficacy.

This Medical Policy does not apply to certain states; specifically, Idaho and Kansas are listed as states to which this policy does not apply, and users are directed to the state‑specific policy versions for those states.

Key Evidence

Revision History

2025-06-01Application updatedLatest

Application section updated to indicate the policy does not apply to Idaho and Kansas and to refer to state-specific policy versions. (Policy History: 06/01/2025 — Application Idaho and Kansas added language.)

2025-04-01Clinical evidence and references updated; previous policy archived

Supporting information updated in Clinical Evidence and References sections to reflect the most current information; previous policy version CSO75.S archived. (Policy effective date: April 1, 2025.)