CurrentUnitedHealthcarePolicy CS075KY.07

Manipulation Under Anesthesia (for Kentucky Only)

UnitedHealthcare Community Plan medical policy specific to Kentucky governing medical necessity and coverage positions for manipulation under anesthesia (MUA) by joint/site, listing covered indications (knee for arthrofibrosis after TKA/surgery/fracture; shoulder for adhesive capsulitis per InterQual criteria), not medically necessary uses, exclusions, applicable procedure and diagnosis codes, and supporting evidence references.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kentucky Only)

Policy CodePolicy CS075KY.07

Change TypeRevision (definitions & supporting info)

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder joint MUA for adhesive capsulitis, providers must reference and meet the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075KY.06.

2Covered Joint Indications (site-specific)

9Listed Not-Covered Sites (examples)

12Referenced Procedure/HCPCS Codes

Coverage Summary

Scope: UnitedHealthcare Community Plan medical policy (Kentucky only), CS075KY.07, effective March 1, 2026 (last reviewed March 1, 2026). This policy governs medical necessity and coverage positions for Manipulation Under Anesthesia (MUA) by joint/site, including referenced procedure (CPT/HCPCS) and diagnosis (ICD-10) codes for informational purposes; benefit, federal/state, or contractual requirements determine actual coverage and reimbursement.

High-level coverage stance: Mixed. Site-specific covered indications: MUA is medically necessary for the knee when treating arthrofibrosis following total knee arthroplasty (TKA), knee surgery, or fracture, and shoulder MUA for adhesive capsulitis (frozen shoulder) is conditionally covered when the provider meets InterQual® CP criteria for shoulder MUA. For all other joints/conditions (including ankle, finger, hip, pelvis, spine, temporomandibular joint, toe, wrist, and knee indications other than postoperative arthrofibrosis after TKA/surgery/fracture) the policy states MUA is unproven and not medically necessary.

Notes: Refer to InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder for shoulder MUA medical necessity criteria. Listed CPT/HCPCS/ICD-10 codes are provided for reference only and do not imply coverage; benefit terms and applicable laws govern coverage determinations.

Policy snapshot

Covered Joint Indications2

Listed Not-Covered Sites9

Referenced Procedure/HCPCS Codes12

Payer / ScopeUnitedHealthcare Community Plan — Kentucky

Policy NumberCS075KY.07

Effective DateMarch 1, 2026

Medical-Necessity Criteria

Medically Necessary

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

ANY of the following

Knee - Arthrofibrosis: Knee joint manipulation under anesthesia for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis: 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

Not Medically Necessary / Unproven

Manipulation under anesthesia is unproven and not medically necessary for all other conditions (single or serial manipulations) due to insufficient evidence of efficacy:

Not Medically Necessary Sites

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

Does Not Apply / Exclusions

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

Exclusions

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

Coding

Referenced CPT / Procedure Codes (informational list)CPT

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 / Unlisted CodeHCPCS

D7830

Manipulation under anesthesia

Relevant ICD-10 Diagnosis Codes (informational list)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 for Shoulder MUA medical necessity

For shoulder joint MUA for adhesive capsulitis, providers must reference and meet the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to establish medical necessity.

Documentation Required

Document indication for knee MUA

When billing for knee MUA, providers should document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication to meet the policy's covered indication.

27570

Billing Rule

Codes are informational; coverage determined by benefits

Listed procedure and diagnosis codes are provided for reference only; inclusion does not guarantee coverage—benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

21073
22505
23700
25259
26340
27198
27275
27570
27860
D7830

Background & Evidence Summary

Background: Manipulation under anesthesia (MUA) is a noninvasive procedure that combines manual joint or spine manipulation with an anesthetic to reduce pain/spasm and break adhesions by allowing specific manipulative and stretching maneuvers while protective reflexes are absent. The policy evaluates evidence on a site-specific basis, finding supportive evidence for postoperative knee arthrofibrosis and limited/insufficient evidence for many other sites.

Definition: 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 summary

High-level knee evidenceMultiple systematic reviews, RCTs, and cohort studies (2018–2025) support MUA for postoperative knee arthrofibrosis with range-of-motion improvements, especially when performed early post-TKA.

Spine/TMJ/other evidenceAvailable studies are limited, heterogeneous, and low quality; evidence does not consistently support safety or long-term efficacy.

Shoulder coverage noteShoulder MUA for adhesive capsulitis is conditionally covered when InterQual criteria are met.