ModifiedUnitedHealthcarePolicy CS075OH.D

Manipulation Under Anesthesia (for Ohio Only)

UnitedHealthcare Community Plan medical policy governing coverage and medical necessity for manipulation under anesthesia (MUA) for members in the state of Ohio, specifying indications determined as proven/medically necessary vs unproven/not medically necessary, referencing InterQual criteria for shoulder MUA and Ohio Administrative Code for review.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Ohio Only)

Policy CodePolicy CS075OH.D

Change TypeRevised definition and supporting information

Effective DateApril 1, 2026

Next Review Date

Key ActionManipulation under anesthesia requests should be reviewed for medical necessity per this policy and referenced InterQual criteria where applicable; the policy applies only to Ohio members.

SourceLink

POLICY UPDATE CHANGES

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

2Covered Indications (knee, shoulder with criteria)

9Not Medically Necessary Indications (examples)

1State-specific (Ohio only)

Coverage Summary

Scope: This policy (CS075OH.D) applies only to UnitedHealthcare Community Plan members in the state of Ohio and governs coverage and medical necessity determinations for Manipulation Under Anesthesia (MUA) (Effective: April 1, 2026; Last review: April 1, 2026).

Overview: Evidence and coverage stance are mixed. MUA is considered proven/medically necessary for the knee to treat arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and for the shoulder to treat adhesive capsulitis when specified InterQual clinical criteria are met. MUA is unproven/not medically necessary for other joints/conditions (including ankle, finger, hip, pelvis, spine, temporomandibular joint, toe, wrist) due to insufficient evidence. The policy history notes a material update on 04/01/2026 revising the definition of Arthrofibrosis and updating clinical evidence and references.

Medical Necessity Criteria

Medically Necessary (Proven) Indications

Manipulation under anesthesia is proven and medically necessary for the following when clinical criteria are met:

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Medically Necessary (Proven) Indications

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Not Medically Necessary / Unproven Indications

Manipulation under anesthesia 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 or adhesive capsulitis of the hip: Hip joint or adhesive capsulitis of the hip
Knee - conditions other than arthrofibrosis: Knee joint - any condition other than for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture

Exclusions / Not Applicable Scenarios

This policy does not apply to the following procedures/conditions:

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

Referenced 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).

Referenced HCPCS / Dental Procedure CodeHCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 Diagnosis Codes (examples provided)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 & Requirements

Prior Authorization

Prior Authorization / Medical Necessity Review

Manipulation under anesthesia requests should be reviewed for medical necessity per this policy and referenced InterQual criteria where applicable; the policy applies only to Ohio members.

Note: This policy applies only to Ohio members.

Documentation Required

Use of InterQual for Shoulder MUA Criteria

For shoulder MUA, providers must meet medical necessity clinical coverage criteria as defined in InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder; documentation should reference InterQual determination.

Reference InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder.

Documentation Required

State Rule for Unproven/Quantity-Limited Services

Requests for services stated as unproven or with coverage/quantity limits will be evaluated using Ohio Administrative Code 5160-1-01; include documentation to support medical necessity per OAC when applicable.

Submit supporting documentation per Ohio Administrative Code 5160-1-01 when applicable.

Background & Supporting Evidence

Background: Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual manipulation of a joint or the spine with an anesthetic to allow mobilization of a joint when pain, spasm, muscle contracture, or guarding prevents tolerated manipulation. Anesthetics used may include general anesthesia, mild sedation, local injection, or other anesthetic medication. Under anesthesia, protective reflexes are absent, facilitating specific manipulative techniques, passive stretches, and maneuvers intended to break up fibrous adhesions and scar tissue around the joint and surrounding tissue. The effectiveness of MUA varies by joint; evidence is strongest for the knee (postoperative arthrofibrosis after TKA) and selected shoulder adhesive capsulitis when InterQual criteria are met, while evidence for spine, TMJ, toe, ankle, hip, wrist, finger, pelvis is limited or unfavorable.

Definition — Arthrofibrosis: Arthrofibrosis is 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).

Randomized trial (2024, Abdel et al.): In a multicenter randomized trial of 124 participants after total knee arthroplasty and subsequent stiffness, MUA produced an immediate mean range-of-motion improvement of +46°; there was no long-term difference between groups receiving adjunctive anti-inflammatory therapy versus control at 6 weeks and 1 year.

Systematic review/meta-analysis (Patel et al. 2025): A systematic review and meta-analysis (53 studies, 2,931,517 individuals) identified risk factors associated with postoperative knee stiffness requiring MUA after primary total knee arthroplasty, including younger age, Black race, smoking, lower ASA score, and prior knee procedure.

Single-institution retrospective study (Walsh et al. 2024): Among cases of MUA or arthroscopic lysis of adhesions plus MUA after primary TKA, MUAs performed earlier postoperatively had lower revision rates and greater final knee flexion gains compared with combined procedures; reported expected flexion gains in successful cases were in the range of ~27° to 33°.

Multiple systematic reviews (2022–2025): Systematic reviews and meta-analyses (including Fackler et al. 2022, Haffar et al. 2022, Gu et al. 2018, Akhtar et al. 2024) report overall support for knee MUA in postoperative arthrofibrosis with improvements in ROM and functional scores, while evidence for other joints (spine, TMJ, toe, ankle, hip, finger, wrist, pelvis) is limited, inconsistent, or does not demonstrate consistent benefit.

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