CurrentUnitedHealthcarePolicy CS075NM.C

Manipulation Under Anesthesia (for New Mexico Only)

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia applicable only to New Mexico members; defines medically necessary indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual criteria), lists not medically necessary indications, exclusions, applicable codes, definitions, evidence summary, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for New Mexico Only)

Policy CodePolicy CS075NM.C

Change TypeRevised definition; updated supporting evidence

Effective DateMarch 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference and document compliance with the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075NM.B.

2Covered Indications (explicit in policy)

9Not Medically Necessary joints/conditions listed

11Referenced procedure/diagnosis codes

Coverage Summary

UnitedHealthcare Community Plan coverage criteria for Manipulation Under Anesthesia (MUA) applies only to New Mexico members, effective March 1, 2026. The policy defines MUA as a procedure combining manual manipulation with anesthetic to address joint stiffness. Headline covered indications are MUA for knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and MUA for shoulder adhesive capsulitis (frozen shoulder) when InterQual clinical criteria are met. The policy takes a mixed coverage stance — supporting knee arthrofibrosis and shoulder adhesive capsulitis per InterQual, while describing other joints/conditions as unproven or not medically necessary.

Key policy facts

Effective DateMarch 1, 2026

Policy NumberCS075NM.C

StatusCURRENT

ScopeUnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia applicable only to New Mexico members; defines medically necessary indications (knee arthrofibrosis post‑TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual criteria), lists not medically necessary indications and exclusions, and references applicable codes and evidence.

Medical Necessity / Coverage Criteria

Medically necessary

Manipulation under anesthesia is proven and medically necessary for:

ANY of the following

Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder joint 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.
Operational: See InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for required clinical coverage criteria.

Not medically necessary / Unproven

Manipulation under anesthesia is unproven and not medically necessary for all other conditions (whether for single or serial manipulations), including but not limited to:

ALL of the following

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

Exclusions / Not covered scenarios (policy does not apply to)

This policy does not apply to the following:

ALL of the following

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

Provider Actions & Billing Impact

Documentation Required

Use InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis, medical necessity requires meeting the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria; providers must reference and document compliance with InterQual criteria.

Reference and document compliance with InterQual criteria.

Documentation Required

Document indication for knee MUA

For knee MUA, providers must document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and supporting clinical information (e.g., failed conservative therapy and ROM limitations) to justify medical necessity.

Examples of supporting documentation: failed conservative therapy (physical therapy, injections, etc.)
Range of motion (ROM) measurements showing limitation (pre-MUA ROM < 90° commonly reported in studies)
Documentation of arthrofibrosis following TKA, knee surgery, or fracture

Denial Risk

Denial risk for non-covered joints/conditions

Claims for MUA performed for joints or conditions listed as unproven/not medically necessary (e.g., ankle, finger, hip, spine, TMJ, toe, wrist, and knee indications other than arthrofibrosis post‑TKA/surgery/fracture) are subject to denial as not medically necessary.

Ankle
Finger
Hip joint (including hip adhesive capsulitis)
Spine
Temporomandibular joint (TMJ)
Toe
Wrist
Knee indications other than arthrofibrosis following total knee arthroplasty, knee surgery, or fracture

Coding

Referenced CPT / Procedure codes (for reference only)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 HCPCSHCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 diagnosis codes (examples related to covered indications)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.

Background, Evidence Summary, and Definitions

Manipulation under anesthesia (MUA) is a noninvasive procedure that combines manual manipulation of a joint with administration of anesthetic (general, sedative, local injection, or other agents) to permit manipulation in patients who cannot tolerate awake procedures because of pain, spasm, contracture, or guarding.

The policy supports MUA for postoperative knee arthrofibrosis (particularly following total knee arthroplasty, knee surgery, or fracture) and for shoulder adhesive capsulitis when the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria are met. For many other joints (spine, temporomandibular joint, toe, ankle, hip, wrist, finger, pelvis) the evidence is limited, inconsistent, or low quality, and MUA is described as unproven and not medically necessary for those indications.

The evidence base for knee MUA includes multiple systematic reviews, cohort studies, and randomized controlled trials from 2018–2025 reporting range-of-motion (ROM) gains, risk factors for needing MUA, and mixed findings about timing and adjunctive therapies. Examples include a large 2025 systematic review identifying predictors of postoperative stiffness, retrospective series and registry analyses showing clinically meaningful flexion gains after MUA, and RCTs (eg, a 2024 multicenter RCT) showing substantial immediate ROM improvement but similar longer-term outcomes with or without specific anti-inflammatory adjuncts. Overall, studies report variable timing effects (early vs delayed) and mixed results for adjunctive treatments, with heterogeneity and methodological limitations across studies. Evidence for MUA in other joints is limited and generally low quality.

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 Scope & Applicability

This UnitedHealthcare Community Plan policy applies only to New Mexico members and specifies which indications for MUA are considered medically necessary (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual) and which are not medically necessary. The policy document defines covered and not-covered indications, lists applicable CPT/HCPCS/ICD-10 codes for reference, provides definitions and an evidence summary, and includes a policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for New Mexico Only)

Policy CodePolicy CS075NM.C

Change TypeRevised definition; updated supporting evidence

Effective DateMarch 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference and document compliance with the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria.

SourceLink

On This Page

OpenPayer

Manipulation Under Anesthesia (for New Mexico Only)

Coverage Summary

Medical Necessity / Coverage Criteria

Provider Actions & Billing Impact

Coding

Background, Evidence Summary, and Definitions

Revision History

Policy Scope & Applicability