CurrentUnitedHealthcarePolicy CS075KS.02

Manipulation Under Anesthesia (for Kansas Only)

UnitedHealthcare Community Plan medical policy CS075KS.02 governs coverage for manipulation under anesthesia (MUA) for members in Kansas, specifying indications considered medically necessary (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual criteria) and listing joints/conditions considered unproven/not medically necessary or excluded.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kansas Only)

Policy CodePolicy CS075KS.02

Change TypeDefinitions & Supporting Information Updated

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, document that the member meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria; coverage is dependent on meeting those criteria.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived prior policy version CS075KS.01.

2Covered Indications (explicit)

9Not Medically Necessary/Unproven

10Procedure codes listed

Coverage Summary

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Scope summary: UnitedHealthcare Community Plan medical policy CS075KS.02 (Effective March 1, 2026) governs Manipulation Under Anesthesia (MUA) for members in Kansas, specifying covered and not-covered indications for this procedure.

Summary of covered indications: MUA is considered medically necessary for the knee joint to treat arthrofibrosis following total knee arthroplasty (TKA), knee surgery, or fracture, and for the shoulder joint to treat adhesive capsulitis (frozen shoulder) when the member meets the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria.

High-level not-covered stance: MUA is unproven and not medically necessary for other joints and conditions (including but not limited to ankle, finger, hip, pelvis, spine, temporomandibular joint, toe, and wrist) due to insufficient evidence of efficacy.

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary when the following specific joint/condition criteria are met:

ANY of the following

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

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:

ALL of the following

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

Exclusions / Not Applicable

This policy does not apply to the following procedures:

ALL of the following

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

Coding (reference lists)

Procedure CPT / HCPCS Codes (reference list)mixed

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 (reference list related to knee/shoulder ankylosis/adhesive capsulitis)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 & Billing Guidance

Documentation Required

Use InterQual criteria for shoulder MUA coverage determination

For shoulder adhesive capsulitis, document that the member meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria; coverage is dependent on meeting those criteria.

Billing Rule

Code reference guidance

Report the applicable CPT/HCPCS/D code for the joint manipulated (codes listed in policy are provided for reference; inclusion does not guarantee coverage — coverage depends on federal/state/contractual requirements).

21073
22505
23700
25259
26340
27198
27275
27570
27860
D7830

Background, Evidence & Definitions

Manipulation under anesthesia (MUA) is a noninvasive procedure that combines manual manipulation of a joint or the spine with an anesthetic to permit breaking adhesions and improving range of motion for individuals who cannot tolerate awake manual procedures (e.g., due to pain, spasm, or guarding).

Supported indications: Evidence in the policy supports MUA as medically necessary for the knee to treat arthrofibrosis after total knee arthroplasty, knee surgery, or fracture, with multiple systematic reviews, studies, and a randomized trial demonstrating clinically meaningful range-of-motion gains and treatment effect in this setting. For the shoulder, MUA is considered medically necessary for adhesive capsulitis (frozen shoulder) only when the member meets the InterQual CP clinical criteria referenced in the policy.

Insufficient evidence for other joints: The policy states MUA is unproven and not medically necessary for many other joints and conditions (including spine and temporomandibular joint), noting the literature for these sites is limited by small sample sizes, lack of high-quality controlled studies, inconsistent results, and inadequate long-term safety/effectiveness data.

Evidence Type	Summary
Randomized trial (Abdel et al. 2024)
Multicenter randomized trial (n=124) of MUA after TKA found immediate mean ROM improvement of 46° (from 72° to 118°) after MUA; ROM at 6 weeks and 1 year similar between groups randomized to anti-inflammatory adjuvants vs control.
Systematic review/meta-analysis (Patel et al. 2025)
Systematic review and meta-analysis identifying risk factors for requiring MUA after primary TKA (younger age, Black race, smoking, lower ASA score, prior knee procedure) based on 53 studies (2,931,517 individuals).
Multiple systematic reviews (Haffar 2022; Gu 2018; Hopper 2024; Akhtar 2024)
Systematic reviews/meta-analyses support efficacy of MUA for postoperative knee arthrofibrosis with reported mean ROM gains (eg, ~21° average increase after MUA in Haffar; consistent post-TKA ROM improvements in Gu; early vs delayed MUA shows greater mean flexion gain with early MUA per Akhtar; Hopper identifies risk factors after ACLR).
Descriptive/Mechanistic (Reid & Desimone 2002)
Policy description: MUA is a noninvasive procedure combining manual manipulation with anesthesia to break adhesions and improve ROM; theoretical rationale and typical anesthetic approaches described.
Case series / observational (TMJ, toe studies)
Smaller observational studies report variable and sometimes transient improvements for TMJ and first MTP joint MUA; evidence limited by small size and lack of controls.

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).

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