CurrentUnitedHealthcarePolicy CSNCT0515.04

Manipulation Under Anesthesia (for North Carolina Only)

State-specific UnitedHealthcare medical policy (North Carolina) describing coverage determination for manipulation under anesthesia (MUA) by joint/site, clinical criteria references, exclusions, applicable procedure and diagnosis codes, and supporting evidence. It applies only to North Carolina plan members.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for North Carolina Only)

Policy CodePolicy CSNCT0515.04

Change TypeRevised definition; updated Clinical Evidence and References; archived prior version

Effective DateApril 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, reference and document compliance with InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder; for knee MUA, document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections.

2Covered Indications (explicit)

9Not-Covered Sites/Conditions

1External criteria referenced

Coverage Summary

This UnitedHealthcare (North Carolina) medical policy CSNCT0515.04 addresses coverage determinations for Manipulation Under Anesthesia (MUA) by joint/site and summarizes the policy's coverage stance as mixed — some indications are proven and medically necessary while others are considered unproven/not medically necessary. The policy is effective April 1, 2026 and was last reviewed on April 1, 2026.

Medical Necessity Criteria

Medically Necessary (Proven and medically necessary)

Manipulation under anesthesia is proven and medically necessary for:

Medically Necessary

Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder adhesive capsulitis: 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

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:

Not medically necessary / Unproven sites

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

Not Applicable / Policy exclusions

This policy does not apply to the following:

Policy exclusions

Finger - post Xiaflex: Manipulation of the finger on the day following the injection of collagenase clostridium histolyticum (Xiaflex) to treat Dupuytren's contracture
Closed reduction exception: Closed reduction of a fracture or joint dislocation unless specified
Elbow arthrofibrosis excluded: Elbow joint for Arthrofibrosis following elbow surgery or fracture

Provider Actions & Documentation Requirements

Documentation Required

Reference InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis (frozen shoulder), medical necessity requires meeting the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria. Providers must reference those InterQual® criteria in the medical record and document compliance with them when requesting or performing shoulder MUA.

Documentation Required

Document arthrofibrosis after knee surgery

Coverage for knee MUA requires documentation that the indication is arthrofibrosis following total knee arthroplasty, knee surgery, or fracture. Include an appropriate knee arthrofibrosis/ankylosis diagnosis code in the record.

M24.661
M24.662
M24.669

Coding

Referenced CPT / Procedure codes (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), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; 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).

D code - Dental (reference)HCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 diagnosis 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.

Background & Evidence Summary

Background: Manipulation under anesthesia (MUA) is a noninvasive procedure performed with an anesthetic to facilitate manual manipulation of a joint (or the spine) when pain, spasm, muscle contractures, or guarding prevent tolerated manual procedures. Anesthesia may be general, mild sedation, local injection, or other anesthetic approaches to permit short-lever manipulations, passive stretches, and maneuvers intended to break adhesions and scar tissue.

This policy summarizes the evidence for MUA by joint site (for example, knee, spine, temporomandibular joint, toe, etc.) and provides coverage determinations based on the joint-specific evidence, citing systematic reviews, randomized trials, and society guidance.

Summary of evidence entries

Knee — randomized trial (Abdel et al. 2024)MUA produced a mean immediate ROM improvement of 46° (from 72° to 118°); outcomes at 6 weeks and 1 year were similar whether or not anti-inflammatory adjuvants were used

Knee — systematic reviews / meta-analyses (2018–2025)Multiple reviews/meta-analyses report that MUA provides clinically significant ROM gains for postoperative knee arthrofibrosis, with better outcomes when performed earlier; evidence limited by retrospective designs, heterogeneity, and lack of randomized comparisons

Knee — observational studiesLarge retrospective and cohort studies report typical flexion gains (eg, 27–33° in successful cases) and varying failure rates; early MUA associated with larger gains and fewer complications compared with delayed MUA

Spine / TMJ / Toe evidence statementEvidence is limited and low quality; studies show negligible or inconsistent improvements and insufficient evidence of long-term safety or effectiveness — MUA not consistently supported for spine, temporomandibular joint, or toe

Glossary — Arthrofibrosis: Arthrofibrosis is defined as "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)."