CurrentUnitedHealthcarePolicy CS075.U

Manipulation Under Anesthesia – Community Plan Medical Policy

UnitedHealthcare Community Plan medical policy CS075.U defining medical necessity, noncoverage, applicable codes, definitions, clinical evidence summaries, and state-specific applicability for manipulation under anesthesia procedures across joints.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia – Community Plan Medical Policy

Policy CodePolicy CS075.U

Change TypeTemplate, definitions, and references updated

Effective DateMar 1, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

Definitions: Updated definition of 'Arthrofibrosis'.

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

Template Update: Removed content/language pertaining to the state of Louisiana.

Archived previous policy version CS075.T

04/01/2026 Template Update removed content/language pertaining to the state of Louisiana.

03/01/2026 Definitions: Updated definition of 'Arthrofibrosis'.

03/01/2026 Supporting Information: Updated Clinical Evidence and References sections.

Archived previous policy version CS075.T.

2Medically necessary joints (knee, shoulder)

9Joints/conditions listed as unproven/not medically necessary

Coverage Summary

Overview: This UnitedHealthcare Community Plan coverage policy CS075.U addresses Manipulation Under Anesthesia (MUA) and defines medical necessity, noncoverage, applicable procedure and diagnosis codes, clinical evidence summaries, and state-specific applicability for MUA procedures across joints. Effective date: March 1, 2026. Last review: April 1, 2026. Policy number: CS075.U.

Quick facts — scope-specific

Joints with explicit medically necessary indications2

Joints/conditions listed as unproven/not medically necessary9

States with separate policy guidance11

Medical-Necessity Criteria

Medically Necessary (Proven and Medically Necessary)

Manipulation under anesthesia is proven and medically necessary for:

ANY of the following

Knee - Arthrofibrosis following TKA/surgery/fracture: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis per InterQual: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met (refer to InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder)

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:

Unproven/Not Medically Necessary

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

Exclusions / Not Applicable Cases

This policy does not apply to the following specific scenarios:

Exclusions

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

Coding

Procedure CPT / HCPCS codes referencedCPT|HCPCS

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)
D7830	Manipulation under anesthesia (D-code)

Diagnosis codes referenced (examples)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 & Guidance

Documentation Required

Use InterQual criteria for shoulder MUA

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

Documentation Required

State-specific policy applicability

This Medical Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted.

Idaho
Indiana
Kansas
Kentucky
Nebraska
New Jersey

Background & Evidence Summary

Background: Manipulation under anesthesia combines manual manipulation of a joint or the spine with anesthetic agents to treat restricted joint motion caused by pain, spasm, contracture, or guarding. The procedure may be performed under general anesthesia, mild sedation, or local anesthetic and permits maneuvers intended to break up fibrous adhesions and scar tissue around the joint and surrounding tissues.

Evidence strength: According to the policy, the best-supported indications are for the knee (arthrofibrosis following total knee arthroplasty, knee surgery, or fracture) and for the shoulder (adhesive capsulitis) under InterQual criteria. Evidence for other joints — including spine, temporomandibular joint, ankle, toe, hip, pelvis, wrist, and finger — is limited, inconsistent, or unproven; the policy states MUA is unproven and not medically necessary for those other conditions. Note: For shoulder adhesive capsulitis, InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria are referenced for medical necessity determinations.

Evidence	Key finding
Systematic review (Patel et al., 2025)	Identified risk factors for MUA after TKA: younger age, Black race, smoking, lower ASA scores, and prior knee procedure.
Randomized trial (Abdel et al., 2024)	MUA produced mean immediate ROM improvement of 46°; no difference with addition of anti-inflammatory meds at 6 weeks and 1 year.
Systematic review (Fackler et al., 2022) and others (2022-2025)	Generally support efficacy of MUA/LOA for post-TKA arthrofibrosis with significant ROM improvements but variable timing and outcomes; studies limited by heterogeneity and study quality.
Retrospective and cohort studies (Walsh et al., 2024; Pierce et al., 2017; Fabricant et al., 2018)	MUA associated with clinically meaningful flexion gains (typical successful gains ~27°–33°); not associated with increased revision risk in matched analyses; outcomes vary by timing and concomitant procedures.
Evidence for spine, TMJ, toe, ankle, finger, hip, pelvis, wrist (various studies and reviews)	Limited, inconsistent, or low-quality evidence — overall negligible or unproven benefit for these joints compared with knee and shoulder indications.

Definitions

Definitions: 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)."

Definition note: The policy documents that the definition of "Arthrofibrosis" was updated on 03/01/2026.

Revision History

04/01/2026revisedLatest

Template Update: Removed content/language pertaining to the state of Louisiana.

04/01/2026revised

Template Update: Removed content/language pertaining to the state of Louisiana. (Administrative/template update removing Louisiana-specific content.)

03/01/2026revised

Definitions: Updated definition of 'Arthrofibrosis'.