CurrentUnitedHealthcarePolicy N/A

Manipulation under anesthesia (MUA) for arthrofibrosis after total knee arthroplasty

This UnitedHealthcare medical policy provides coverage guidance, definitions, evidence references, and revision history for manipulation under anesthesia (MUA) including clinical context of arthrofibrosis after total knee arthroplasty. It is an informational/coverage-assist policy to be applied with specific plan contract terms.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation under anesthesia (MUA) for arthrofibrosis after total knee arthroplasty

Policy CodePolicy N/A

Change TypeRevised definitions and references

Effective DateMar 1, 2026

Next Review Date

Key ActionWhen deciding coverage, reference the federal, state or contractual requirements for the specific benefit plan as they may differ from this standard policy; in the event of conflict, the plan governs.

POLICY UPDATE CHANGES

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

UpdatedEvidence/References

UpdatedDefinitions

Coverage summary and scope

This UnitedHealthcare medical policy provides coverage guidance, definitions, evidence references, and revision history for manipulation under anesthesia (MUA) including the clinical context of arthrofibrosis after total knee arthroplasty. It is an informational/coverage-assist policy to be applied with specific plan contract terms. Effective Date: 2026-03-01; Last Review: 2026-03-01.

Provider documentation and administration notes

Documentation Required

Use policy in conjunction with plan benefits

This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, reference the federal, state, or contractual requirements for the specific benefit plan as they may differ from this standard policy; in the event of conflict, the plan governs. Before using this policy, check the federal, state, or contractual requirements for benefit plan coverage. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Medical Policy is provided for informational purposes and does not constitute medical advice.

Reference federal, state, or contractual benefit plan requirements when deciding coverage
If there is a conflict between this policy and plan requirements, the federal/state/contract governs
Check applicable plan requirements before using this policy

Documentation Required

Reference third-party criteria

UnitedHealthcare may use third-party tools, such as the InterQual criteria, to assist in administering benefits. Providers should be prepared to supply documentation consistent with those criteria when requested.

Be prepared to provide documentation consistent with InterQual or other third-party criteria if requested

Background, evidence and definitions

This is the second part of the UnitedHealthcare policy on Manipulation Under Anesthesia (Policy CS075.U). It includes references and supporting clinical evidence, instructions for use, and the policy's revision history (including the Summary of Changes dated 03/01/2026 noting updates to the definition of 'Arthrofibrosis' and the Clinical Evidence and References sections).

Recent publications cited in the policy include multiple studies and reviews from 2018–2025 such as a 2024 multicenter randomized clinical trial (Abdel et al., J Arthroplasty 2024), systematic reviews and meta-analyses (e.g., Pat el et al. 2025; Hopper et al. 2024; Akhtar et al. 2024), retrospective series and cohort studies (Walsh et al. 2024; Grace et al. 2023), and pertinent systematic reviews on arthroscopic lysis of adhesions and MUA (Fackler et al. 2022; Gu et al. 2018), which are listed in the References section.

Definitions

ArthrofibrosisA 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: definition updated in policy on 03/01/2026.

Coding

No code groups are provided in this document; coding and the clinical coverage criteria (including applicable procedure and diagnosis codes when relevant) are included in the companion policy part. Refer to the companion policy for CPT/HCPCS and diagnosis code listings and for plan-specific billing guidance.

Policy revision history

2026-03-01RevisedLatest

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections to reflect the most current information; archived previous policy version CS075.T (Summary of Changes dated 03/01/2026 notes definitions and supporting information updates and archives previous policy version CS075.T).