CurrentUnitedHealthcarePolicy CS075PA.R

Manipulation Under Anesthesia Pa Cs

UnitedHealthcare medical policy (Pennsylvania only) defining medical necessity for manipulation under anesthesia (MUA) by anatomic site, citing covered indications (knee arthrofibrosis post-TKA/ knee surgery/fracture and shoulder adhesive capsulitis per InterQual criteria), not medically necessary uses, applicable CPT/HCPCS and ICD-10 codes, and supporting evidence and references.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia Pa Cs

Policy CodePolicy CS075PA.R

Change TypeDefinitions and supporting information updated (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, refer to and document 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

2Explicitly covered joint indications

9Joints/conditions not medically necessary/unproven

1State-specific applicability (Pennsylvania only)

Coverage Summary

UnitedHealthcare (Pennsylvania only) medical policy CS075PA.R (effective April 1, 2026; last reviewed April 1, 2026) defines medical necessity for Manipulation Under Anesthesia (MUA) by anatomic site. MUA is considered medically necessary for the knee joint to treat arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and for the shoulder joint to treat adhesive capsulitis (frozen shoulder) when clinical coverage criteria are met per InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder. MUA for other joints/conditions is listed as unproven and not medically necessary (including ankle, finger, hip, pelvis, spine, TMJ, toe, wrist, and any knee indication other than the arthrofibrosis indications above). This policy applies only to Pennsylvania; requests not meeting PARP criteria may be evaluated case-by-case per Pennsylvania Code, Title 55, Chapter 1101.

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary when ALL of the following apply for the specified joint:

ALL of the following

Procedure is manipulation under anesthesia of the knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture

Medically Necessary - Shoulder

Manipulation under anesthesia is medically necessary for the shoulder when ALL of the following are met:

ALL of the following

Diagnosis of adhesive capsulitis (frozen shoulder) of the shoulder (ICD-10 codes M75.00, M75.01, M75.02, or M24.611/M24.612/M24.619 for ankylosis) or as specified by InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder
Provider must refer to InterQual criteria for specific clinical entry requirements
Clinical coverage criteria met per InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder
Provider must refer to InterQual criteria for specific clinical entry requirements

Not Medically Necessary / Unproven

Manipulation under anesthesia is considered unproven and not medically necessary for ALL of the following joints/conditions (insufficient evidence of efficacy):

ONE of

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

Exclusions / Not Applicable

This policy does not apply to the following procedures:

ANY 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

Coding

Reference CPT / Procedure codes listedCPT

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)

HCPCS / OtherHCPCS

D7830

Manipulation under anesthesia

Relevant ICD-10 Diagnosis codes (examples referenced)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 Required

Use InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis requests, providers must reference and document the InterQual® Clinical Practice (CP) criteria for Procedures, Manipulation Under Anesthesia, Shoulder when requesting coverage. The InterQual CP defines the specific clinical entry requirements that must be met.

Clinical coverage criteria met per InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder
Providers should include documentation showing how the patient meets the InterQual entry requirements when submitting the request

Documentation Required

State-specific applicability

This policy applies only to the state of Pennsylvania. Any requests for services that do not meet the Pennsylvania Access to Care/Provider-specific rules (PARP) criteria may be evaluated on a case-by-case basis. When applicable, providers should reference Pennsylvania Code, Title 55, Chapter 1101 for Pennsylvania-specific exception/case-by-case processes.

Policy scope: Pennsylvania only
Refer to Pennsylvania Code, Title 55, Chapter 1101 for case-by-case evaluation guidance

Background, Evidence & Definitions

Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual manipulation with anesthetic agents (general anesthesia, sedation, local injection, or other agents) to reduce pain, muscle guarding, and break up adhesions/scar tissue to improve joint range of motion. Evidence is strongest for MUA in the knee to treat postoperative arthrofibrosis following total knee arthroplasty or other knee surgery (multiple systematic reviews, cohort studies, and randomized trial data show clinically meaningful ROM gains, especially when performed earlier after surgery). For the shoulder, MUA may be medically necessary when InterQual® clinical coverage criteria for adhesive capsulitis are met. Evidence for spinal and other peripheral joints (TMJ outside certain AAOMS guideline contexts, ankle, hip, toe, finger, pelvis, wrist) is limited, heterogeneous, or low quality and is insufficient to support routine use of MUA for those indications.

Evidence type	Key findings (source wording, codes, thresholds)
Randomized trial (Abdel et al. 2024)	MUA produced immediate ROM gains; outcomes similar at 6 weeks and 1 year irrespective of anti-inflammatory adjuvant (randomized trial of 124 participants; ROM improved mean 46° immediately; 6-week and 1-year ROM similar between groups).
Systematic reviews/meta-analyses (multiple 2018-2025)	Support for knee MUA after TKA with clinical ROM improvements; timing (early vs delayed) affects gain and complication risk (reviews and meta-analyses report improved ROM post-MUA, greater gains with earlier MUA, and higher complication/revision risk with delayed MUA).
Knee - additional observational studies/case series	Multiple cohort and single‑institution studies report clinically significant flexion gains (eg, 20–33° in successful cases), improved PROMs, low complication rates in many series; limitations include retrospective designs and heterogeneity.
Spine and other joints - limited/low-quality evidence	Evidence for spine, TMJ, ankle, hip, toe, finger, pelvis, wrist is limited, heterogeneous, and low-quality; insufficient to support routine use or demonstrates negligible/uncertain benefit.

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)