CurrentUnitedHealthcarePolicy CS075KS.02

Manipulation Under Anesthesia (for Kansas Only)

State-specific UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applicable only to Kansas members; defines medically necessary indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual), lists noncovered/unproven indications, related exclusions, applicable CPT/HCPCS and ICD-10 codes, and supporting clinical evidence.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kansas Only)

Policy CodePolicy CS075KS.02

Change TypeDefinition and supporting information updates

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, apply InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder to determine medical necessity and document the InterQual criteria used and supporting clinical records.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated clinical evidence and references; archived previous policy version CS075KS.01.

2Covered Indications (explicit)

9Listed Unproven/Not Medically Necessary Joints/Conditions

11Referenced CPT/HCPCS Codes

Coverage Summary

This policy applies to Kansas UnitedHealthcare Community Plan members and addresses coverage for Manipulation Under Anesthesia (MUA). Status: CURRENT (effective March 1, 2026; last review March 1, 2026). Scope: state-specific policy for Kansas. Coverage stance: mixed — MUA is considered medically necessary/proven for two explicit indications: knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and shoulder adhesive capsulitis (frozen shoulder) when InterQual criteria are met. All other joints/uses are listed as unproven/not medically necessary.

Policy facts

Policy numberCS075KS.02

PayerUnitedHealthcare

JurisdictionKansas

Effective dateMarch 1, 2026

Last reviewMarch 1, 2026

Coverage stancemixed

Covered Indications (explicit)2

Listed Unproven/Not Medically Necessary Joints/Conditions9

Referenced CPT/HCPCS Codes11

Medical Necessity — Indications and Exclusions

Medically Necessary Indications

Manipulation under anesthesia is proven and medically necessary for:

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

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Medically Necessary Indications

Not Medically Necessary / Unproven Indications

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

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

Exclusions / Not Applicable

This policy does not apply to 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

Provider Actions and Documentation Requirements

Documentation Required

Use InterQual for shoulder MUA clinical criteria

For shoulder adhesive capsulitis, apply InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder to determine medical necessity; document the InterQual criteria used and include supporting clinical records.

Document the specific InterQual criteria applied
Attach supporting clinical records demonstrating criteria are met

Documentation Required

Document indication for knee MUA

For knee MUA, document diagnosis of Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, including supporting clinical history and prior conservative therapies.

27570

Denial Risk

Denial risk for noncovered joints/conditions

Claims for MUA performed for joints/conditions listed as unproven/not medically necessary (e.g., ankle, finger, hip, spine, TMJ, toe, wrist, and knee indications other than post-TKA/surgery/fracture) are subject to denial as not medically necessary.

21073
22505
25259
26340
27275
27860

CPT / HCPCS / ICD-10 Codes

Referenced Procedure CPT CodesCPT

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 / D Codemixed

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

Background and Evidence Summary

Manipulation under anesthesia (MUA) combines manual manipulation of a joint or the spine with an anesthetic agent (general anesthesia, sedation, or local anesthetic) to facilitate breaking adhesions and improving range of motion by allowing passive stretches and specific maneuvers without protective reflexes.

The evidence base is strongest for MUA in treating knee arthrofibrosis after total knee arthroplasty (TKA), supported by multiple systematic reviews, retrospective studies, and randomized trials showing clinically significant gains in range of motion and functional outcomes when nonoperative measures fail, particularly when performed earlier postoperatively.

For the shoulder (adhesive capsulitis), InterQual clinical criteria are required to determine medical necessity; when those InterQual criteria are met, MUA is considered medically necessary for frozen shoulder per this policy.

Evidence for MUA in the spine, temporomandibular joint (TMJ), toe, ankle, finger, hip, pelvis, wrist, and other joints is limited, inconsistent, or of low quality (small sample sizes, retrospective designs, lack of controls), and therefore MUA for these indications is considered unproven and not medically necessary.

Evidence & definition

Evidence summaryMultiple systematic reviews and RCTs (Abdel 2024 RCT; multiple 2022-2025 reviews/studies) support efficacy for post-TKA knee stiffness; evidence for other joints/spine/TMJ/toe is limited, low-quality, or inconsistent.

Definition: ArthrofibrosisA 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).

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kansas Only)

Policy CodePolicy CS075KS.02

Change TypeDefinition and supporting information updates

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Manipulation Under Anesthesia (for Kansas Only)

Coverage Summary

Medical Necessity — Indications and Exclusions

Provider Actions and Documentation Requirements

CPT / HCPCS / ICD-10 Codes

Background and Evidence Summary

Revision History