CurrentunitedhealthcarePolicy CS075NJ.P

Manipulation Under Anesthesia (for New Jersey Only)

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) that applies only to New Jersey members; defines indications considered medically necessary (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis when InterQual criteria met), lists noncovered/unproven indications, related exclusions, applicable codes, definitions, and supporting evidence summaries.

Policy Summary

Payerunitedhealthcare

PolicyManipulation Under Anesthesia (for New Jersey Only)

Policy CodePolicy CS075NJ.P

Change TypeDefinition and supporting information updates

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder to determine medical necessity and required clinical criteria; obtain applicable preauthorization per the member's plan and New Jersey rules.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections to reflect current information; previous policy version CS075NJ.O archived.

2Covered Indications (explicit)

9Not-Medically-Necessary Joints/Conditions

10Referenced Procedure Codes

Coverage Summary

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UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applies only to New Jersey members and defines indications considered medically necessary and not medically necessary. MUA is covered as medically necessary for the knee joint for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and for the shoulder for adhesive capsulitis (frozen shoulder) when the InterQual clinical criteria for shoulder MUA are met. MUA is considered unproven and not medically necessary for other joints and conditions listed in the policy (including ankle, finger, hip, pelvis, spine, temporomandibular joint, toe, wrist and any knee indications other than postoperative arthrofibrosis). The policy also lists related exclusions, applicable reporting codes, and updated supporting evidence and definitions.

Key Facts

Effective DateMarch 1, 2026

Last ReviewMarch 1, 2026

Policy NumberCS075NJ.P

PayerUnitedHealthcare

Geographic ScopeNew Jersey only

Coverage StanceMixed — medically necessary for knee arthrofibrosis post‑TKA/surgery/fracture and for shoulder adhesive capsulitis when InterQual criteria met; unproven/not medically necessary for other joints/conditions

Medical Necessity and Unproven Indications

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

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

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Not Medically Necessary / Unproven

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 - other: Knee joint - any condition other than for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Pelvis

Exclusions / Not Applicable

This policy does not apply to the following:

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

Provider Actions & Billing Requirements

Prior Authorization

Prior authorization where applicable per plan

Policy provides coverage guidance but plan, federal, state, or contractual requirements govern; provider should obtain applicable preauthorization per member's plan and state rules (New Jersey only).

Documentation Required

Use InterQual for shoulder MUA clinical criteria

For shoulder adhesive capsulitis, the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder must be referenced to determine medical necessity and required clinical criteria.

Billing Rule

Reporting CPT/HCPCS/D codes

Report the applicable procedure code consistent with the service provided; listing of codes is informational and does not guarantee coverage—verify benefit and authorization.

21073
22505
23700
25259
26340
27198
27275
27570
27860
D7830

Referenced Procedure CPT/HCPCS/D Codes (informational only)mixed

21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (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)

Referenced Diagnosis (ICD-10) CodesICD-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 is a noninvasive procedure combining manual manipulation of a joint or the spine with an anesthetic to overcome pain, spasm, muscle contractures, or guarding and allow maneuvers to break up fibrous adhesions and scar tissue. The evidence is strongest for the knee—particularly for arthrofibrosis following total knee arthroplasty or other knee surgery or fracture—with multiple systematic reviews, retrospective studies, and randomized trials demonstrating range-of-motion improvements and commonly better outcomes when performed earlier. For the shoulder, MUA may be medically necessary for adhesive capsulitis when specific InterQual criteria are met. Evidence for the spine, temporomandibular joint, toe, ankle, hip, wrist, finger, and pelvis is limited, of low quality, or insufficient to support routine use.

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).

Evidence Type/Source	Summary
Systematic review / meta-analysis (Patel et al. 2025)
Identified risk factors for post-TKA stiffness requiring MUA (younger age, Black race, smoking, lower ASA, prior knee surgery); limitations include retrospective designs and heterogeneity.