CurrentUnitedHealthcarePolicy CS075NJ.P

Manipulation Under Anesthesia (for New Jersey Only)

UnitedHealthcare Community Plan medical policy (New Jersey only) defining when manipulation under anesthesia is considered medically necessary vs not medically necessary across joints, listing applicable CPT/HCPCS/ICD-10 codes, exclusions, background and evidence summaries. It references InterQual criteria for shoulder MUA.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for New Jersey Only)

Policy CodePolicy CS075NJ.P

Change TypeDefinitions / Clinical Evidence update

Effective DateMar 1, 2026

Next Review Date

Key ActionDocument that shoulder MUA meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria and for knee MUA document Arthrofibrosis following TKA, knee surgery, or fracture with supporting clinical information and prior rehabilitation attempts.

SourceLink

POLICY UPDATE CHANGES

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

2Covered Joint Indications (knee, shoulder with criteria)

9Not-medically-necessary joints/conditions listed

1External criteria referenced (InterQual)

Coverage Summary

Manipulation under anesthesia (MUA) is a noninvasive procedure that combines manual manipulation of a joint or the spine with an anesthetic to overcome pain, spasm, muscle contracture, or guarding; anesthetic approaches include general anesthesia, mild sedation, local injection, or other medication-assisted techniques. Because protective reflexes are absent under anesthesia, specific manipulations and stretches can be used to break up adhesions and scar tissue around the joint and surrounding tissues.

This policy applies to UnitedHealthcare Community Plan members in New Jersey and defines when MUA is considered medically necessary versus not medically necessary across different joints. The coverage stance is mixed: MUA is supported and considered medically necessary for specific knee and shoulder indications (with shoulder requiring InterQual criteria documentation), while it is considered unproven and not medically necessary for many other joints and for spinal MUA due to insufficient evidence.

Policy dates and identifiers (effective/last review/policy number)

Covered Joint IndicationsKnee: Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture; Shoulder: adhesive capsulitis (frozen shoulder) when InterQual CP criteria are met.

Not-Medically-Necessary Joints/ConditionsAnkle; Finger; Hip or hip adhesive capsulitis; Knee conditions other than post-TKA arthrofibrosis; Pelvis; Spine; Temporomandibular joint; Toe; Wrist.

External criteria referenced (InterQual)InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder is required for shoulder MUA medical necessity decisions; providers must document meeting InterQual criteria.

Medically Necessary and Not Medically Necessary Indications

Medically Necessary Indications

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

Medically necessary joint indications

Knee arthrofibrosis indication: Knee joint manipulation under anesthesia for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder adhesive capsulitis 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
Requires meeting InterQual CP shoulder criteria

Not Medically Necessary / Unproven Indications

Manipulation under anesthesia is unproven and not medically necessary for all other conditions due to insufficient evidence of efficacy, including but not limited to:

Unproven / not medically necessary indications

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

Procedures / Situations Excluded from This Policy

This policy does not apply to the following:

Exclusions from policy

Finger after Xiaflex: Manipulation of the finger on the day following the 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 exclusion: Elbow joint for Arthrofibrosis following elbow surgery or fracture

Referenced Procedure and Diagnosis Codes

Referenced CPT / Procedure Codes (informational list)CPT

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)

Referenced HCPCS / Other CodesHCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 Diagnosis Codes (examples related to knee/shoulder adhesive/ankylosis)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 Documentation & Billing Actions

Documentation Required

Shoulder MUA requires InterQual criteria documentation

Shoulder manipulation under anesthesia is considered medically necessary only when the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria are met. Providers must document that the patient meets those InterQual criteria in the medical record when requesting or delivering shoulder MUA.

External criteria referenced: InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder

Documentation Required

Knee MUA indication documentation

For knee manipulation under anesthesia, providers must document that the indication is Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and include supporting clinical information such as the patient history and prior rehabilitation attempts in the medical record when requesting or delivering knee MUA.

Affected CPT code: 27570

Background and Evidence Summary

Manipulation under anesthesia (MUA) combines manual manipulation with an anesthetic (general, mild sedation, or local injection) to allow stretching and mobilization of joints by reducing pain and muscle guarding. It is intended to break up fibrous adhesions and scar tissue around joints and surrounding tissues to improve range of motion.

Evidence summarized in this policy supports MUA for knee arthrofibrosis following total knee arthroplasty (TKA) or other knee surgery or fracture, with multiple systematic reviews, retrospective series, and randomized trials reporting clinically meaningful improvements in range of motion and functional scores—especially when performed earlier postoperatively. A multicenter randomized trial and several meta-analyses/systematic reviews demonstrate ROM gains after MUA for post-TKA stiffness. Shoulder MUA for adhesive capsulitis (frozen shoulder) is considered medically necessary only when InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria are met. For many other joints (ankle, finger, hip, pelvis, toe, wrist, temporomandibular joint) and for spinal MUA, the evidence is limited, inconsistent, or insufficient to support routine use, and these indications are listed as unproven and not medically necessary.

Multiple systematic reviews and randomized trials (2024–2025) support the efficacy of MUA for postoperative knee stiffness after TKA, showing significant immediate and sustained improvements in range of motion and functional outcomes, with earlier MUA generally associated with larger gains and lower complication/revision rates. In contrast, studies of MUA for the spine, temporomandibular joint, toe, ankle, hip, wrist, and other joints are limited by small sample sizes, lack of control groups, methodological weaknesses, and inconsistent results, leaving evidence for those indications insufficient to establish effectiveness.

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).