CurrentUnitedHealthcarePolicy CS075PA.R

Manipulation Under Anesthesia (for Pennsylvania Only)

UnitedHealthcare Community Plan Medical Policy (Pennsylvania only) that defines when manipulation under anesthesia (MUA) is considered medically necessary versus not medically necessary for specific joints/conditions, references InterQual for shoulder criteria, lists applicable procedure and diagnosis codes, and provides background and evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Pennsylvania Only)

Policy CodePolicy CS075PA.R

Change TypeDefinitions and Clinical Evidence updated

Effective DateApr 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, providers must reference and document compliance with InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075PA.Q.

2Covered Indications (knee arthrofibrosis; shoulder subject to InterQual)

9Not Medically Necessary Joint Sites Listed

1State-specific scope (Pennsylvania only)

Coverage Summary

Scope: UnitedHealthcare Community Plan Medical Policy (Pennsylvania only) that defines when manipulation under anesthesia (MUA) is considered medically necessary versus not medically necessary for specific joints/conditions, references InterQual for shoulder criteria, lists applicable procedure and diagnosis codes, and provides background and evidence summaries.

Lead / Policy ID: Policy Number CS075PA.R; Subject: Manipulation Under Anesthesia (Pennsylvania only); Effective Date / Last Review: April 1, 2026.

Policy Metadata

Policy NumberCS075PA.R

Policy TitleManipulation Under Anesthesia (for Pennsylvania Only)

PayerUnitedHealthcare

ScopePennsylvania only

Effective DateApril 1, 2026

Last ReviewApril 1, 2026

StatusCURRENT

Coverage stance summary: Mixed — Manipulation under anesthesia is proven and medically necessary for certain indications (see medically necessary criteria) and is unproven and not medically necessary for other conditions.

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

Medical Necessity Criteria

Medically Necessary

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

ANY of the following

Knee - arthrofibrosis: Knee joint manipulation for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - adhesive capsulitis: Shoulder joint manipulation for adhesive capsulitis (frozen shoulder) when certain criteria are met; for medical necessity clinical coverage criteria, refer to InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder
Providers must reference and document compliance with InterQual criteria when requesting coverage.

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Medically Necessary

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Not Medically Necessary / Unproven

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:

Not medically necessary / unproven joint sites

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

Exclusions / Not Covered Situations

This policy does not apply to the following situations:

Exclusions

Xiaflex finger manipulation: Manipulation of the finger on the day following the injection of collagenase clostridium histolyticum (Xiaflex®) to treat Dupuytren contracture
Closed reduction exclusion: Closed reduction of a fracture or joint dislocation unless specified

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Coding

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).

Proprietary/Other Procedure Codemixed

D7830

Manipulation under anesthesia (D code)

Referenced 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 & Documentation

Documentation Required

Follow InterQual criteria for shoulder MUA

When requesting coverage for manipulation under anesthesia (MUA) of the shoulder for adhesive capsulitis, reference and document compliance with InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder. Include specific documentation showing how the patient meets each InterQual criterion for medical necessity (e.g., clinical findings, prior conservative treatments and durations, objective range-of-motion measurements, and timing).

Reference InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder in the request.
Provide clinical documentation of adhesive capsulitis diagnosis (e.g., ICD-10 code, ROM measurements).
Document prior conservative treatments and duration (physical therapy, medications, injections) and response.
State how the patient meets each InterQual criterion being relied upon.

Documentation Required

State-specific application

This policy applies only to Pennsylvania. Requests for services that do not meet the policy criteria will be evaluated on a case-by-case basis. Where applicable, reference Pennsylvania Code, Title 55, Chapter 1101 for Pennsylvania-specific exceptions.

Policy scope is limited to Pennsylvania only.
Nonconforming requests will be reviewed case-by-case.
Reference: Pennsylvania Code, Title 55, Chapter 1101 when relevant.

Background & Evidence Summary

Background: Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual manipulation of a joint or the spine with an anesthetic (general, sedation, or local injection) to reduce pain/spasm and facilitate breaking adhesions. Because protective reflexes are absent under anesthesia, clinicians may perform specific manipulations, passive stretches, and kinesthetic maneuvers to break fibrous adhesions and scar tissue around the joint and surrounding tissue. Evidence varies by joint: the policy cites the strongest support for MUA to treat knee arthrofibrosis after total knee arthroplasty (TKA) with multiple systematic reviews, observational studies, and at least one randomized trial showing immediate ROM gains and clinically meaningful improvements in many cases; shoulder MUA for adhesive capsulitis has conditional support when InterQual® criteria are met.

Study / Topic	Finding
Knee - systematic review (Patel et al., 2025)
Identified risk factors for MUA after primary TKA from 53 studies (2,931,517 individuals); younger age, Black race, smoking, lower ASA score, and prior knee procedure associated with increased risk
Knee - RCT (Abdel et al., 2024)
MUA produced immediate mean ROM improvement (~46°); no long‑term ROM difference between adjuvant anti‑inflammatory vs control at 6 weeks and 1 year
Spine
Evidence insufficient and low quality; studies show limited, inconsistent benefits and methodological limitations, so MUA not supported as effective for spine
TMJ
Mixed/limited evidence; some patients improve but studies lack controls and findings are inconsistent

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.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Pennsylvania Only)

Policy CodePolicy CS075PA.R

Change TypeDefinitions and Clinical Evidence updated

Effective DateApr 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, providers must reference and document compliance with InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder when requesting coverage.

SourceLink

On This Page

OpenPayer

Manipulation Under Anesthesia (for Pennsylvania Only)

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Documentation

Background & Evidence Summary

Revision History