CurrentUnitedHealthcarePolicy CS075KY.07

Manipulation Under Anesthesia (for Kentucky Only)

UnitedHealthcare Kentucky medical policy defining when manipulation under anesthesia (MUA) is considered proven/medically necessary (knee for arthrofibrosis after TKA/surgery/fracture; shoulder for adhesive capsulitis per InterQual criteria), and listing conditions for which MUA is unproven/not medically necessary and exclusions. Includes applicable CPT/CPT-like and ICD-10 codes for reference and supporting clinical evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kentucky Only)

Policy CodePolicy CS075KY.07

Change TypeRevised (definitions, clinical evidence, references)

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis MUA, providers must meet InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder medical necessity criteria; InterQual is used as the primary medical/surgical criteria.

SourceLink

POLICY UPDATE CHANGES

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

2Covered Indications

9Unproven/Not Medically Necessary

1State-specific (Kentucky only)

Coverage Summary

UnitedHealthcare Kentucky medical policy CS075KY.07 defines when Manipulation Under Anesthesia (MUA) is considered proven/medically necessary and when it is unproven/not medically necessary. Coverage is state-specific to Kentucky and the policy number is CS075KY.07. The policy states MUA is medically necessary for the knee for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and for the shoulder for adhesive capsulitis when InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria are met; it lists multiple other joints/conditions as unproven or not medically necessary.

Policy dates and status

effective2026-03-01

last_review2026-03-01

statusCURRENT

policy_numberCS075KY.07

state_scopeKentucky only

Medically Necessary / Not Medically Necessary / Exclusions

Medically Necessary

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

ANY of the following

Knee joint MUA for Arthrofibrosis following total knee arthroplasty (TKA), knee surgery, or fracture
Coverage applies only for arthrofibrosis following TKA, knee surgery, or fracture
Shoulder joint MUA for adhesive capsulitis (frozen shoulder) when certain criteria are met
Adhesive capsulitis coverage requires meeting InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria

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:

ALL of the following

Ankle
Finger
Hip joint or adhesive capsulitis of the hip
Knee joint for any condition other than arthrofibrosis following TKA, knee surgery, or fracture
Pelvis
Spine
Temporomandibular joint (TMJ)

Exclusions / Not Applicable

This policy does not apply to the following procedures/clinical scenarios:

ALL of the following

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

Provider Actions & Documentation Requirements

Documentation Required

Shoulder MUA requires InterQual criteria

InterQual is the primary medical/surgical criteria source for shoulder MUA (adhesive capsulitis). Providers must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder medical necessity criteria when requesting coverage for shoulder MUA.

InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder

Documentation Required

Limit knee MUA coverage to specific indications

Limit coverage of knee manipulation under anesthesia to arthrofibrosis that follows total knee arthroplasty (TKA), prior knee surgery, or fracture. Providers must document the indication and clinical history showing arthrofibrosis in these contexts when submitting for coverage. Applicable CPT code reference: 27570.

CPT 27570

Documentation Required

Benefit determination may vary

Benefit determination may be subject to federal, state, or contractual requirements that can differ from this policy; when conflicts exist, those federal/state/contractual requirements govern. Check applicable benefit plan terms before using this policy for coverage decisions.

CPT / HCPCS / ICD-10 Codes (Reference)

CPT / Procedure codes (reference)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).

HCPCS / D code (reference)HCPCS

D7830

Manipulation under anesthesia

ICD-10 Diagnosis codes (reference for Knee)ICD-10

M24.661	Ankylosis, right knee.
M24.662	Ankylosis, left knee.
M24.669	Ankylosis, unspecified knee.

ICD-10 Diagnosis codes (reference for Shoulder)ICD-10

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, Evidence Summary & Definitions

Manipulation under anesthesia (MUA) is a noninvasive procedure combining manual manipulation with an anesthetic (general anesthesia, sedation, local injection, oral agents, or other anesthetic therapies) to help break fibrous adhesions and improve joint range of motion by eliminating protective reflexes that limit aggressive stretching and specific articular maneuvers.

Evidence for efficacy is strongest for the knee—particularly for arthrofibrosis after total knee arthroplasty (TKA), knee surgery, or fracture—and for shoulder adhesive capsulitis when patients meet specified InterQual criteria. For many other joints, including the spine and temporomandibular joint (TMJ), and for procedures on the ankle, finger, hip, pelvis, toe, and wrist, the evidence is limited, inconsistent, or insufficient to support routine use.

Systematic review/meta-analysis (Patel et al. 2025): Identified risk factors for post-TKA stiffness requiring MUA across 53 studies (n=2,931,517); significant associations included younger age, Black race, smoking, lower ASA score (≤2), and prior knee procedure.

Randomized trial (Abdel et al. 2024): In a multicenter randomized trial (n=124), MUA produced an immediate mean ROM improvement of 46°; at 6 weeks and 1 year there were no differences in ROM between groups randomized to MUA with or without an anti-inflammatory adjuvant.

Multiple systematic reviews and cohort studies (2018–2025): Reviews and observational studies consistently support efficacy of MUA for post-TKA stiffness—particularly when performed early—with typical flexion gains reported in the 20°–33° range and better outcomes with earlier intervention; by contrast, studies of spinal MUA, TMJ, toe, and other joints are small, uncontrolled, or heterogeneous and provide insufficient high-quality evidence to demonstrate consistent 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).

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Kentucky Only)

Policy CodePolicy CS075KY.07

Change TypeRevised (definitions, clinical evidence, references)

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Manipulation Under Anesthesia (for Kentucky Only)

Coverage Summary

Medically Necessary / Not Medically Necessary / Exclusions

Provider Actions & Documentation Requirements

CPT / HCPCS / ICD-10 Codes (Reference)

Background, Evidence Summary & Definitions

Revision History