CurrentUnitedHealthcarePolicy CSNCT0515.03

Manipulation Under Anesthesia (for North Carolina Only)

State-specific UnitedHealthcare medical policy for Manipulation Under Anesthesia (MUA) that governs coverage determinations in North Carolina, specifying conditions considered proven/medically necessary, conditions considered unproven/not medically necessary, applicable codes, and references to InterQual criteria for shoulder.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for North Carolina Only)

Policy CodePolicy CSNCT0515.03

Change TypeState-specific version; updated evidence/references

Effective DateApr 1, 2025

Next Review Date

Key ActionFor shoulder adhesive capsulitis, follow the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity clinical coverage criteria.

POLICY UPDATE CHANGES

Created state-specific policy version for the state of North Carolina (no change to coverage guidelines).

Supporting Information - Updated Clinical Evidence and References sections to reflect the most current information.

2Proven/Medically Necessary Indications (knee, shoulder)

9Unproven/Not Medically Necessary joints/conditions

11CPT/Procedure Codes referenced

Coverage Summary

State-specific UnitedHealthcare medical policy for Manipulation Under Anesthesia (MUA) that governs coverage determinations in North Carolina. Effective date: April 1, 2025; Last review: November 1, 2025. MUA combines manual manipulation of a joint or the spine with anesthesia to treat pain, spasm, muscle contractures, or guarding when manual procedures are not tolerated. Coverage stance: mixed — MUA is considered proven/medically necessary for certain indications (knee arthrofibrosis post-TKA and shoulder adhesive capsulitis per InterQual criteria) and is unproven/not medically necessary for many other joints and conditions.

Policy NumberCSNCT0515.03

ScopeNorth Carolina — state-specific UnitedHealthcare medical policy

Coverage StanceMixed (proven for select indications; unproven for others)

Effective Date2025-04-01

Last Reviewed2025-11-01

Medical‑Necessity Criteria

Medically Necessary (Proven) Indications

MUA is proven and medically necessary for the following when criteria are met:

Medically Necessary Indications

Knee - Arthrofibrosis after TKA/surgery/fracture: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis (see InterQual): 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
Refer to InterQual clinical criteria for detailed medical necessity requirements for shoulder MUA.

Not Medically Necessary / Unproven Indications

MUA 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 Indications

Ankle
Finger
Hip joint or adhesive capsulitis of the hip
Knee - other than arthrofibrosis post-TKA/surgery/fracture: Knee joint - any condition other than Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Pelvis
Spine

Exclusions / Situations Where Policy Does Not Apply

This policy does not apply to the following procedures or scenarios:

Exclusions / Nonapplicable Scenarios

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

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 ring 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).

HCPCSHCPCS

D7830

Manipulation under anesthesia

Diagnosis Codes referenced (examples for Knee/Shoulder)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

Refer to InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis, follow the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity clinical coverage criteria.

Documentation Required

State-specific applicability

This Medical Policy only applies to the state of North Carolina; providers must check federal, state, or contractual requirements as they may govern coverage in case of conflict.

Background & Evidence Summary

Manipulation under anesthesia (MUA) is a non-invasive procedure combining manual manipulation of a joint or the spine with administration of an anesthetic to facilitate manipulation in individuals who cannot tolerate manual procedures due to pain, spasm, muscle contractures, or guarding. The policy recognizes evidence supporting MUA for treatment of knee arthrofibrosis following total knee arthroplasty (TKA) — including randomized trials and systematic reviews demonstrating clinically significant improvements in range of motion, particularly when performed within 12 weeks post-operatively — and for shoulder adhesive capsulitis when InterQual clinical criteria are met. Evidence is insufficient, inconsistent, or limited for MUA of many other joints and conditions (including spine/SMUA, TMJ, ankle, finger, hip, pelvis, toe, wrist), and MUA for those indications is considered unproven and not medically necessary.

Evidence type	Key point
Randomized trial (Abdel et al. 2024)	Multicenter RCT (n=124) showed MUA after TKA produced a mean immediate ROM improvement of 46° (p<.001); ROM similar between adjunct dexamethasone/celecoxib and control at 6 weeks and 1 year.
Systematic reviews / meta-analyses (Gu 2018; Haffar 2022; Hopper 2024; Akhtar 2024)	Reviews report clinically significant ROM gains after MUA for postoperative knee arthrofibrosis (best outcomes if performed ≤12 weeks); early MUA may yield greater gain and lower complication/revision rates than delayed MUA; overall evidence quality and heterogeneity limit definitive conclusions.
Observational studies / case series (various: Frackler 2022, Fabricant 2018, Grace 2023, others)	Multiple case series and cohort studies report improved ROM and patient-reported outcomes after knee MUA with low complication rates; limitations include nonrandomized designs and variable follow-up.
Spine / SMUA evidence (narrative reviews, small studies)	Evidence is limited, methodologically weak, and inconsistent; some small uncontrolled studies show short-term improvement but reviews conclude insufficient evidence to support SMUA for low back pain and long‑term safety/effectiveness is not established (ACOEM does not recommend).
Temporomandibular joint (TMJ) and other joints (toe, ankle, hip, wrist, finger, pelvis)	Studies are small, inconsistent, and of low quality; MUA may produce short-term ROM gains in some reports (e.g., TMJ, first MTPJ) but overall evidence is insufficient to support routine use for TMJ or other non-knee joints.

Arthrofibrosis: A complication of injury or trauma where 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).

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