CurrentUnitedHealthcarePolicy CSO7SID.B

Manipulation Under Anesthesia (for Idaho Only)

UnitedHealthcare Community Plan medical policy applicable to the state of Idaho (including Idaho Medicaid Plus) defining coverage and noncoverage determinations for manipulation under anesthesia (MUA) by anatomic site, with associated codes, definitions, supporting evidence, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Idaho Only)

Policy CodePolicy CSO7SID.B

Change TypeSupporting information updated (clinical evidence & references)

Effective DateAug 1, 2025

Next Review Date

Key ActionFor shoulder adhesive capsulitis coverage, providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria as the medical necessity standard.

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence and References sections to reflect the most current information.

2Explicitly covered site-indications

9Unproven/not medically necessary sites (examples)

1State applicability (Idaho only)

Coverage Summary

This policy covers Manipulation Under Anesthesia (MUA), a procedure combining manual joint manipulation with anesthesia to address joint stiffness and arthrofibrosis. It is applicable to the state of Idaho (including Idaho Medicaid Plus) and defines covered and not‑covered anatomic sites and indications. The policy takes a mixed coverage stance: MUA is medically necessary for the shoulder for adhesive capsulitis when InterQual clinical necessity criteria are met and for the knee to treat arthrofibrosis following total knee arthroplasty (TKA), knee surgery, or fracture. Evidence is limited or insufficient to support routine use of MUA for other joints (including the spine and temporomandibular joint [TMJ]) and for other knee conditions not related to postoperative arthrofibrosis. The policy notes referenced CPT/HCPCS/ICD-10 codes and requires use of InterQual criteria for shoulder MUA medical necessity determination; providers should verify federal/state/contractual benefit requirements and prior authorization rules.

Medical Necessity

Medically Necessary Indications

MUA is proven and medically necessary when ALL of the following anatomic/site-specific criteria are met:

Covered sites/indications (ANY of)

Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met per InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder.
Refer to InterQual clinical coverage criteria for specific clinical necessity requirements.
Knee joint for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.
Applies to arthrofibrosis post-TKA, post knee surgery, or post-fracture.

Not Medically Necessary / Unproven Indications

MUA is considered unproven and not medically necessary for ALL other conditions (including single or serial manipulations) due to insufficient evidence of efficacy; examples include:

Unproven / Not Medically Necessary Sites

Finger
Knee (other than arthrofibrosis post-TKA/surgery/fracture): Knee joint for any condition other than arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Hip (including joint or adhesive capsulitis of the hip)
Pelvis
Spine (spinal manipulation under anesthesia not proven)
Toe
Temporomandibular joint (TMJ)

Procedures / Services Not Covered by This Policy

This policy does not apply to the following procedures/contexts:

Exclusions

Closed reduction exclusion: Closed reduction of a fracture or joint dislocation unless specified
Post-Xiaflex finger manipulation exclusion: Manipulation of the finger following injection of collagenase clostridium histolyticum (Xiaflex) to treat Dupuytren's contracture
Elbow exclusion: Elbow joint for arthrofibrosis following elbow surgery or fracture (policy does not apply)

Coding

Referenced CPT procedure codes (for reference only)CPT

21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service
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
27860	Manipulation of ankle under general anesthesia

Referenced HCPCS codeHCPCS

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

Provider Actions

Documentation Required

Use InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis (frozen shoulder), providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria as the medical necessity standard.

Prior Authorization

Prior authorization applicability (implied)

This medical policy applies to Idaho plans; providers should verify applicable federal, state, and contractual benefit requirements and obtain any required prior authorizations per the member’s plan rules before performing MUA in Idaho.

Denial Risk

Claims risk for non-covered indications

Claims for MUA performed for indications listed as unproven or not medically necessary are at risk for denial. Examples of such noncovered/unproven sites/conditions include spine, temporomandibular joint (TMJ), finger, hip (including joint or adhesive capsulitis of the hip), toe, wrist, ankle, and knee conditions other than arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.

Background & Evidence

Manipulation Under Anesthesia (MUA) is a non‑invasive procedure that pairs manual manipulation of a joint (or spine) with an anesthetic agent to reduce pain, muscle guarding, and break up fibrous adhesions and scar tissue to improve joint mobility. The policy supports MUA for shoulder adhesive capsulitis (frozen shoulder) when InterQual clinical criteria are met and for knee arthrofibrosis after TKA, knee surgery, or fracture. MUA is considered unproven and not medically necessary for other joints/conditions (e.g., spine, TMJ, finger, hip, pelvis, wrist, ankle, toe and knee indications other than arthrofibrosis post‑TKA/surgery/fracture) due to insufficient evidence of efficacy.

Evidence Source	Summary
Randomized controlled trial (2024) - TKA MUA outcomes	RCT (Abdel et al., 2024) with 124 post-TKA patients showed immediate mean ROM improvement (~46°) after MUA; ROM similar between groups at 6 weeks and 1 year; limitations include lack of masking.
Systematic reviews/meta-analyses (2022-2024) - knee arthrofibrosis	Multiple systematic reviews and meta-analyses (Gu et al. 2018; Frackler et al. 2022; Haffar et al. 2022; Akhtar et al. 2024; Hopper et al. 2024) report MUA can improve ROM after TKA or ACLR-related arthrofibrosis; earlier MUA associated with greater gains and fewer complications versus delayed; overall evidence limited by heterogeneity and low-quality studies.
Spine/TMJ/other joints	Evidence for spine, TMJ, and other non-knee/shoulder joints is limited and methodologically weak (small samples, lack of controls); professional bodies (ACOEM) do not recommend MUA/MASM for low back; studies show inconsistent/insufficient support for routine use.

Arthrofibrosis: A complication of injury or trauma where 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.