CurrentUnitedHealthcarePolicy CS075TN.R

Manipulation Under Anesthesia (for Tennessee Only)

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applicable to Tennessee Medicaid and CoverKids; defines medically necessary indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual criteria), lists non-covered/unproven indications, related codes, definitions, supporting evidence, and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Tennessee Only)

Policy CodePolicy CS075TN.R

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

Effective DateMar 1, 2026

Next Review Date

Key ActionFor knee MUA, document arthrofibrosis following TKA, knee surgery, or fracture including history, diagnosis codes, prior conservative therapy and timing; for shoulder MUA, document meeting InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

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

2Indications Classified as Proven/Medically Necessary

9+Conditions Listed as Unproven/Not Medically Necessary

1State-specific policy (Tennessee)

Coverage Summary

UnitedHealthcare Community Plan medical policy CS075TN.R for Manipulation Under Anesthesia (MUA) applies to Tennessee Medicaid and CoverKids and defines the covered and non-covered indications, referenced codes, supporting evidence, and policy history. The policy is effective March 1, 2026 and was last reviewed on March 1, 2026.

Scope: The policy designates MUA as medically necessary for two primary indications (knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture; and shoulder adhesive capsulitis when InterQual criteria are met) and classifies MUA as unproven and not medically necessary for other joints/conditions. It also lists applicable CPT/HCPCS/ICD-10 examples and documents recent policy changes, including an updated definition of Arthrofibrosis and revised clinical evidence and references.

Key Policy Facts

Policy (subject)Manipulation Under Anesthesia (Tennessee Medicaid & CoverKids)

PayerUnitedHealthcare

State-specificTennessee

Policy NumberCS075TN.R

Effective DateMarch 1, 2026

Last ReviewMarch 1, 2026

Coverage Stancemixed (medically necessary for knee arthrofibrosis post‑TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual; unproven/not medically necessary for other joints)

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

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. Provider should document criteria per InterQual.

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:

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 (Policy Does Not Apply To)

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

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

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 ExamplesICD-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

Shoulder MUA requires InterQual criteria documentation

For shoulder adhesive capsulitis, medical necessity must meet the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder; provider should document criteria per InterQual.

Document that InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria are met

Documentation Required

Knee MUA indication documentation

For knee MUA, provider must document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture (history, diagnosis codes, prior conservative therapy and timing).

Document history indicating arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Include relevant diagnosis codes (examples: M24.661, M24.662, M24.669)
Document prior conservative therapy and timing (e.g., rehabilitation/exercises and duration prior to considering MUA)

Background, Evidence & Definitions

Manipulation under anesthesia combines manual manipulation with an anesthetic to overcome pain, spasm, or guarding and to break adhesions and improve joint range of motion. The policy notes that the evidence base varies by joint: there is robust and supportive literature for knee arthrofibrosis after total knee arthroplasty (including systematic reviews, retrospective series, and randomized trials showing clinically significant ROM gains), whereas evidence for other joints (spine, TMJ, toe, hip, ankle, wrist) is mixed, limited, or insufficient and often of low methodological quality.

The policy specifically focuses coverage on knee arthrofibrosis following TKA, knee surgery, or fracture (recognized as a medically necessary indication) and on shoulder adhesive capsulitis (frozen shoulder) when the InterQual criteria are met; other joint indications are considered unproven and not medically necessary due to insufficient evidence.

Evidence	Summary
Randomized trial (Abdel et al. 2024)	MUA produced an immediate mean ROM improvement of 46° (from 72° to 118°). No difference in ROM or clinical outcomes at 6 weeks or 1 year between MUA plus anti‑inflammatory adjunct versus MUA alone.
Systematic review/meta-analysis (Patel et al. 2025)	Identified risk factors for postoperative knee stiffness requiring MUA after primary TKA: younger age, Black race, smoking, lower ASA score (≤2), and prior knee procedure; limitations include retrospective designs and heterogeneity.
Multiple systematic reviews (Hopper 2024; Fackler 2022; Gu 2018)	Support efficacy of MUA and/or lysis of adhesions for knee arthrofibrosis with clinically meaningful ROM improvements (mean gains reported ~20–41° or greater); evidence limited by nonrandomized designs, heterogeneity, and lack of control groups.
Spine and other joints	Evidence for MUA in the spine, TMJ, toe, ankle, hip, wrist, and other joints is insufficient or low quality; narrative reviews and professional guidance (ACOEM) do not support MUA/MASM for low back pain due to inadequate evidence.

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 Tennessee Only)

Policy CodePolicy CS075TN.R

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

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Manipulation Under Anesthesia (for Tennessee Only)

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background, Evidence & Definitions

Revision History