CurrentUnitedHealthcarePolicy CS075.T

Manipulation Under Anesthesia

UnitedHealthcare medical policy CS075.T addressing coverage, clinical rationale, definitions, applicable codes, evidence, and exclusions for manipulation under anesthesia (MUA) across joints; excludes specific state variations listed in Application.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia

Policy CodePolicy CS075.T

Change TypeSupporting information updatedstate applicability added

Effective DateApr 1, 2025

Next Review Date

Key ActionVerify state-specific applicability; for shoulder adhesive capsulitis MUA, meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Application: Idaho and Kansas added to list of states where this Medical Policy does not apply; refer to state-specific policy versions.

Supporting Information: Clinical Evidence and References sections updated to reflect the most current information; previous policy version archived.

2Covered Indications (joint-specific)

multipleNot medically necessary for listed joints

10Referenced CPT/HCPCS codes

Coverage Summary

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Manipulation under anesthesia (MUA) is a non-invasive procedure that combines manual manipulation of a joint or the spine with an anesthetic to treat joint stiffness and arthrofibrosis; anesthetic approaches may include general anesthesia, mild sedation, local injections, or other agents to permit manipulation that breaks up fibrous adhesions and scar tissue while protective reflexes are suppressed.

The strongest body of evidence and the coverage rationale support MUA for knee arthrofibrosis, particularly following total knee arthroplasty (TKA), knee surgery, or fracture. Evidence for effectiveness in other joints — including the spine, temporomandibular joint (TMJ), ankle, toe, hip, finger, and other joints — is limited or insufficient, and the policy identifies many of these indications as unproven or not medically necessary.

This policy (CS075.T) excludes certain state-specific applicability; providers should verify state policy versions because this Medical Policy does not apply in specified states (for example, Idaho and Kansas were added to the list of non-applicable states in the 06/01/2025 update).

Medical-Necessity Criteria

Medically Necessary

Medically Necessary - top level

Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder adhesive capsulitis: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met
Requires meeting InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder (refer to InterQual for medical necessity clinical coverage criteria)

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Not Medically Necessary / Unproven

Not Medically Necessary / Unproven - top level

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
TMJ: Temporomandibular joint (TMJ) except as noted under AAOMS recommendations for specific TMJ disease (informational only)
AAOMS recommendations for TMJ are informational; see AAOMS Clinical Practice Guidelines

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Exclusions / Not Applicable

Exclusions / Not Applicable - top level

Dupuytren's/Xiaflex: Manipulation of the finger on the day following injection of collagenase clostridium histolyticum (Xiaflex) to treat Dupuytren's contracture
Closed reduction of a fracture or joint dislocation unless specified
Elbow arthrofibrosis policy not apply: Elbow joint for Arthrofibrosis following elbow surgery or fracture (policy does not apply)

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Coding

Procedure codes (referenced for MUA)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)

HCPCSHCPCS

D7830

Manipulation under anesthesia

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 & Requirements

Documentation Required

Shoulder MUA requires InterQual criteria

For shoulder adhesive capsulitis MUA, providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder medical necessity criteria. Refer to the external InterQual criteria for the specific clinical coverage requirements that must be satisfied prior to performing MUA of the shoulder.

View the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder (external InterQual reference)

Documentation Required

State policy applicability check

Verify state-specific applicability before applying policy CS075.T. This Medical Policy does not apply in the following states; refer to the indicated state-specific policy/guideline when applicable.

Idaho
Indiana
Kansas
Kentucky
Louisiana
New Jersey
New Mexico
Ohio
Pennsylvania
Tennessee

Evidence Summary & Definitions

High-quality knee-specific evidence includes a 2024 multicenter randomized controlled trial (Abdel et al.) in which MUA produced an immediate mean improvement in range of motion (ROM) of 46° (from a pre-MUA ROM of 72–118°) and similar ROM and clinical outcomes between randomized groups at 6 weeks and 1 year. Systematic reviews and meta-analyses from 2018 through 2024 consistently report clinically meaningful improvements in ROM after MUA for postoperative knee arthrofibrosis following TKA, with some reviews noting better gains when MUA is performed earlier (within roughly 12 weeks) and reporting mean ROM improvements in the range of ~20–41° depending on the analysis.

The systematic reviews (2022–2024) supporting knee MUA note important limitations: many included studies are nonrandomized, heterogeneous in definitions and timing of arthrofibrosis and MUA, often lack comparison groups, vary in physical therapy regimens, and overall the evidence quality is low to moderate. A 2024 systematic review/meta-analysis comparing early versus delayed MUA found similar post-MUA flexion but greater mean gains and fewer complications with earlier MUA; pooled analyses were limited by variable reporting.

For non-knee joints (spine, TMJ, toe, ankle and others), the evidence is limited, inconsistent, or low quality. Spine and spinal manipulation under anesthesia (SMUA) studies show negligible or uncertain benefits and are limited by small samples, high risk of bias, and inconsistent controls. TMJ, toe, and ankle reports are small case series or retrospective reviews with mixed results and methodological limitations. Professional guidance (AAOMS) includes specific recommendations for TMJ disease in select contexts, but overall the policy characterizes MUA for these other joints as having limited or insufficient evidence of efficacy and potential risks that do not consistently favor the procedure.

Policy administrative updates relevant to the evidence summary include revisions to the Clinical Evidence and References sections effective 04/01/2025 and an entry on 06/01/2025 adding Idaho and Kansas to the states where the medical policy does not apply; these are documentation/administrative changes rather than changes to the substantive coverage rationale.

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).

OpenPayer

Manipulation Under Anesthesia

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Requirements

Evidence Summary & Definitions

Revision History