CurrentUnitedHealthcarePolicy 2026T0515CC

Manipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

UnitedHealthcare Commercial and Individual Exchange medical policy defining medical necessity and noncoverage for manipulation under anesthesia (MUA) by joint/site, with references to InterQual criteria for shoulder MUA and listing applicable CPT/CPT-like and ICD-10 codes. Applies to commercial and individual exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0515CC

Change TypeDefinitions; Clinical Evidence & References updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument adherence to InterQual criteria for shoulder MUA and document arthrofibrosis following TKA, knee surgery, or fracture when requesting knee MUA.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections to reflect the most current information.

2Proven/Covered Anatomic Sites (knee, shoulder)

9Unproven/Not Medically Necessary Sites

11Procedure/Reference Codes Listed

Coverage Summary

Scope: This UnitedHealthcare policy defines medical necessity for Manipulation Under Anesthesia (MUA) for Commercial and Individual Exchange plans, organized by anatomic site. The evidence base is supportive for treating knee arthrofibrosis after total knee arthroplasty (TKA), and limited/supporting for shoulder adhesive capsulitis when InterQual clinical criteria are met. Most other anatomic sites, including the spine and temporomandibular joint (TMJ), lack sufficient high-quality evidence to support routine use of MUA.

Background (high level): MUA combines manual joint or spinal manipulation with anesthetic agents to allow more aggressive manipulation in individuals who cannot tolerate it while awake; studies provide the strongest support for knee postoperative arthrofibrosis (multiple systematic reviews, case series, and randomized data reporting meaningful range-of-motion gains immediately after MUA) and conditional support for shoulder when InterQual criteria are satisfied, whereas evidence for many other joints is limited, methodologically weak, or absent.

Policy metadata

Policy number2026T0515CC

Effective date2026-02-01

Last review2026-02-01

StatusCURRENT

SubjectManipulation Under Anesthesia (MUA)

Medical-Necessity Criteria

Medically Necessary / Proven Indications

Manipulation under anesthesia is proven and medically necessary when the following anatomic-site specific indications are met:

Knee indication: Knee joint manipulation under anesthesia for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Document Arthrofibrosis as the indication to support medical necessity (see policy).
Shoulder indication: Shoulder joint manipulation under anesthesia 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; providers must document adherence to those InterQual clinical criteria.

Not Medically Necessary / Unproven Indications

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:

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

Exclusions / Not Covered Scenarios

This policy does not apply to the following manipulations (excluded from policy coverage determinations):

Xiaflex day-after manipulation: Manipulation of the finger on the day following injection of collagenase clostridium histolyticum (Xiaflex) to treat Dupuytren contracture
Excluded from this policy.
Closed reduction fracture/dislocation: Closed reduction of a fracture or joint dislocation unless specified
Excluded from this policy.
Elbow arthrofibrosis: Elbow joint for Arthrofibrosis following elbow surgery or fracture
Excluded from this policy coverage determinations.

Applicable Codes (reference)

Applicable Procedure CPT / HCPCS / CPT-like codes (reference only)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 (i.e., general anesthesia, moderate sedation, spinal/epidural).
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 (CPT-like dental/other code).

Applicable Diagnosis ICD-10 codes (reference only)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 Requirements

Documentation Required

Shoulder MUA requires InterQual criteria documentation

Medical necessity for shoulder manipulation under anesthesia (MUA) is conditional on meeting the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria. Providers must document adherence to those InterQual clinical criteria in the medical record to support coverage decisions.

Refer to InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder

Documentation Required

Document Arthrofibrosis indication for knee MUA

For knee MUA, providers must document that the indication is Arthrofibrosis occurring after total knee arthroplasty, other knee surgery, or fracture to support medical necessity.

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).

Background, Evidence Summary & Definitions

Manipulation under anesthesia (MUA) is a noninvasive procedure that pairs manual manipulation of a joint or the spine with an anesthetic (general, sedation, local injection, or other agents) to permit aggressive short-lever manipulations, passive stretches, and maneuvers intended to break adhesions and scar tissue when pain, spasm, or contracture prevent tolerated awake therapy. (See policy Description of Services.)

Evidence summarized by anatomic site:

- Knee: Multiple systematic reviews, case series, and randomized or controlled studies support MUA for postoperative knee arthrofibrosis after TKA and other knee surgery or fracture, reporting clinically meaningful immediate and longer-term improvements in range of motion (for example, a multicenter randomized trial reported a mean immediate ROM gain of 46° after MUA and several reviews report consistent ROM improvements and acceptable complication profiles).

- Shoulder: Evidence is limited but supportive when clinical eligibility is documented per InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder; medical necessity for shoulder MUA is contingent on meeting those InterQual clinical coverage criteria and documenting adherence.

- Spine and TMJ (and most other joints such as ankle, finger, hip, pelvis, wrist, toe): The literature is limited, methodologically weak, and inconsistent; narrative reviews and professional guidance note insufficient evidence of long-term safety or efficacy for spinal MUA, and TMJ and many peripheral joints have small uncontrolled series with mixed results, so MUA is considered unproven and not medically necessary for these indications.

Evidence highlights

Definitions