CurrentUnitedHealthcarePolicy CS075OH.D

Manipulation Under Anesthesia (for Ohio Only) – Community Plan Medical Policyopen_in_new

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia that applies only to the state of Ohio, defining medically necessary and not medically necessary indications, related definitions, supporting evidence, and applicable procedure/diagnosis codes.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Ohio Only) – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS075OH.D

Change TypeRevised definition and supporting information

Effective DateApr 1, 2026

Next Review Date

Key ActionEvaluate Ohio requests for services stated as unproven or with coverage/quantity limits using Ohio Administrative Code 5160-1-01.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075OH.C.

2Covered Indications

9Not Medically Necessary Indications

11Referenced CPT/Procedure Codes

Coverage Summary

This Ohio-specific medical policy (Policy Number CS075OH.D, effective 2026-04-01) covers Manipulation Under Anesthesia (MUA), a procedure that combines manual joint or spinal manipulation with anesthesia to permit interventions in individuals who cannot tolerate manipulation because of pain, spasm, muscle contracture, or guarding. Coverage stance for MUA is mixed: MUA is considered medically necessary for specific, joint‑specific indications (notably knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and selected shoulder adhesive capsulitis when InterQual criteria are met), while MUA is not medically necessary (unproven) for many other joints and for spinal MUA. The policy applies only to the state of Ohio and uses Ohio Administrative Code 5160-1-01 for evaluation of services stated as unproven.

Medical Necessity Criteria

Medically Necessary (Proven) Indications

Manipulation under anesthesia is proven and medically necessary when the following joint-specific indications are met:

Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Arthrofibrosis defined per policy: excessive scar tissue response causing painful restriction of joint motion despite rehabilitation exercises
Shoulder adhesive capsulitis: Shoulder joint for adhesive capsulitis (frozen shoulder) when specified InterQual clinical coverage criteria are met
Refer to supporting InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for shoulder criteria; InterQual is used for primary medical/surgical criteria

Not Medically Necessary (Unproven) Indications

Manipulation under anesthesia is unproven and not medically necessary for all other conditions (whether single or serial manipulations) due to insufficient evidence of efficacy, including but not limited to:

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

Exclusions / Not Covered Scenarios

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

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

Provider Actions & Prior Authorization

Prior Authorization

InterQual criteria requirement for shoulder and general use

UnitedHealthcare uses InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder as the primary medical necessity criteria for shoulder MUA and references InterQual for clinical coverage details for shoulder and related MUA determinations. Use InterQual for clinical details when evaluating shoulder MUA requests.

InterQual referenced for shoulder; use InterQual for clinical details

Documentation Required

State-specific medical necessity evaluation

This policy applies only to the state of Ohio. Requests for services that are stated as unproven or that have coverage or quantity limits must be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Ohio Administrative Code 5160-1-01

Denial Risk

Denial for unproven indications

Claims for MUA for indications listed in this policy as unproven or not medically necessary are considered not medically necessary and are subject to denial.

Ankle
Finger
Hip joint (including hip adhesive capsulitis)
Spine
Temporomandibular joint (TMJ)
Toe
Wrist
Knee conditions other than arthrofibrosis following TKA/knee surgery/fracture

Documentation Required

Clinical documentation of arthrofibrosis

For knee MUA, document that arthrofibrosis is related to total knee arthroplasty, prior knee surgery, or fracture per the policy definition (excessive scar tissue response causing painful restriction of joint motion that persists despite rehabilitation). Include documentation of prior rehabilitation attempts.

Include the policy definition of arthrofibrosis (excessive scar tissue response with painful restriction of joint motion)
Document prior rehabilitation attempts

Coding (Referenced Procedure & Diagnosis Codes)

Referenced CPT/Procedure Codes (for reference only)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)

Dental/Other Procedure CodeHCPCS

D7830

Manipulation under anesthesia

Applicable Diagnosis Codes (examples related to covered indications)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

Background & Evidence Summary

Manipulation under anesthesia (MUA) entails combining manual manipulation of a joint or the spine with an anesthetic (which may include general anesthesia, monitored anesthesia care, sedation, local injection, or other anesthetic agents) so that specific short‑lever manipulations, passive stretches, and kinesthetic maneuvers can be performed to break up fibrous adhesions and scar tissue in individuals unable to tolerate awake manipulation. Evidence is strongest supporting MUA for knee arthrofibrosis after total knee arthroplasty or other knee surgery and for selected cases of shoulder adhesive capsulitis when InterQual clinical criteria are met. By contrast, the published literature for many other joints and for spinal MUA is limited, of low quality, or inconsistent, and the evidence is insufficient or unfavorable to support MUA for those indications.

Evidence Summary

RigorMultiple systematic reviews, randomized trials, cohort and retrospective studies summarized; evidence strongest for post-TKA knee arthrofibrosis MUA

Knee outcomesRandomized trial (Abdel 2024) and multiple systematic reviews/cohort studies report immediate and sustained ROM gains (mean flexion gains reported, variable complication rates)

Spine/TMJ/other jointsEvidence insufficient or low quality; narrative and systematic reviews report limited or negligible support for efficacy

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).