CurrentUnitedHealthcarePolicy CS075TN.R

Manipulation Under Anesthesia (for Tennessee Only)

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (Tennessee Medicaid and CoverKids only) specifying covered indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual), listing noncovered/unproven indications, applicable CPT/HCPCS/ICD-10 codes, definitions, clinical evidence summary, and policy administrative details.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Tennessee Only)

Policy CodePolicy CS075TN.R

Change TypeRevised (definitions and supporting info)

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, document that the case meets InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria; for knee MUA, document arthrofibrosis related to TKA, knee surgery, or fracture and supporting clinical information (history, failed rehabilitation, ROM limitations).

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075TN.Q.

2Primary covered joint indications

9Unproven / not medically necessary joint sites

10+Referenced codes provided

Coverage Summary

This UnitedHealthcare Community Plan medical policy (Policy Number CS075TN.R) addresses Manipulation Under Anesthesia (Tennessee Medicaid and CoverKids only). The policy effective date is March 1, 2026 and the document status is CURRENT.

Scope: specifies covered indications (knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture; and shoulder adhesive capsulitis when InterQual CP criteria are met), lists unproven/not medically necessary indications for other joints (e.g., ankle, spine, TMJ, toe, hip, wrist, pelvis, finger), includes applicable CPT/HCPCS/ICD-10 codes, a definition for arthrofibrosis, clinical evidence summary, and policy administrative details.

Coverage stance: mixed — knee MUA and select shoulder MUA are considered medically necessary under specified conditions, while MUA for other joints/conditions is considered unproven and not medically necessary due to insufficient evidence.

Primary coverage stats (policy)

Primary covered joint indications2

Listed unproven/not medically necessary joint sites9

Referenced CPT/HCPCS/ICD-10 codes provided10+

Medical-Necessity Criteria

Medically Necessary / Covered Indications

Manipulation under anesthesia is proven and medically necessary when ALL specified conditions for the indicated joints are met:

ALL of the following

Knee: For the knee joint: Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Covered for arthrofibrosis after TKA, knee surgery, or fracture
Shoulder: For the shoulder joint: Adhesive capsulitis (frozen shoulder) when certain criteria are met per InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder
Reference to InterQual criteria required for clinical coverage details

Not Medically Necessary / Unproven Indications

Manipulation under anesthesia is unproven and not medically necessary for all other conditions (single or serial manipulations) due to insufficient evidence:

Examples include but are not limited to

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

Excluded / Policy Does Not Apply To

This policy does not apply to the following specific situations:

Exclusions

Finger after Xiaflex injection: 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 arthrofibrosis: Elbow joint for Arthrofibrosis following elbow surgery or fracture

Provider Actions & Documentation Requirements

Documentation Required

Reference InterQual criteria for shoulder MUA

Document that the shoulder adhesive capsulitis case meets the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria. Include the InterQual reference as the coverage criteria used to determine medical necessity for shoulder MUA in the member’s record.

Documentation Required

Document indication of arthrofibrosis for knee procedures

For knee MUA, document that the indication is arthrofibrosis related to total knee arthroplasty, prior knee surgery, or fracture. In the record include supporting clinical information: relevant history, evidence of failed rehabilitation, and objective range-of-motion limitations consistent with arthrofibrosis.

Background and Evidence Summary

Manipulation under anesthesia (MUA) combines manual manipulation of a joint or the spine with an anesthetic agent to permit mobilization in individuals who cannot tolerate awake manipulation because of pain, spasm, muscle contractures, or guarding. Anesthetics used may include general anesthesia, mild sedation, local injection, or other agents to reduce protective reflexes and allow maneuvers intended to break up fibrous adhesions and scar tissue around the joint.

Clinical rationale: by eliminating protective reflex mechanisms, clinicians can perform specific manipulative stretches and articular maneuvers to disrupt adhesions and improve range of motion (ROM) when conservative rehabilitation has failed.

Joints addressed: the policy emphasizes the knee (arthrofibrosis following TKA, knee surgery, or fracture) and the shoulder (adhesive capsulitis when InterQual criteria are met) as covered indications, and notes other joints (spine, TMJ, ankle, toe, hip, wrist, finger, pelvis) are generally considered unproven or not medically necessary due to insufficient evidence.

Evidence summary: Multiple systematic reviews, randomized trials, and observational studies (2018–2025) are cited. For the knee after total knee arthroplasty (TKA), randomized trials and systematic reviews report clinically significant improvements in range of motion (ROM) following MUA, with better gains reported when MUA is performed earlier post‑TKA in many studies.

Systematic reviews / RCTs: cited high-quality evidence includes a multicenter randomized clinical trial (Abdel et al., 2024) and several systematic reviews/meta-analyses (e.g., Gu et al. 2018; Haffar et al. 2022; Akhtar et al. 2024; Patel et al. 2025) demonstrating ROM improvements and identifying risk factors and timing considerations for knee MUA.

Key finding (knee MUA): RCTs and systematic reviews report clinically meaningful ROM gains (examples: immediate mean ROM increases of ~46° in a randomized trial; pooled/series gains and improved outcomes when MUA is performed earlier post‑TKA).

Key finding (spine/TMJ/other): evidence for spinal MUA, TMJ, toe, hip, ankle and other joints is limited, methodologically weak, heterogeneous, or inconsistent; reviews and guideline statements conclude there is insufficient high-quality evidence to support routine coverage for these indications.

Arthrofibrosis — defined term

TermArthrofibrosis

DefinitionA 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).