CurrentUnitedHealthcarePolicy CS075ID.B

Manipulation Under Anesthesia Id Cs

UnitedHealthcare Community Plan medical policy applicable to Idaho (including Idaho Medicaid Plus) defining medical necessity and noncoverage for Manipulation Under Anesthesia (MUA) by joint/site, with clinical evidence summary, exclusions, and applicable procedure/diagnosis codes. It references InterQual criteria for shoulder MUA.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia Id Cs

Policy CodePolicy CS075ID.B

Change TypeRevised (Clinical Evidence/References)

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument adherence to InterQual criteria for shoulder MUA and for knee MUA provide documentation supporting arthrofibrosis after TKA, knee surgery, or fracture including history, exam, and prior rehabilitation attempts.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information

2Covered Joint Indications (knee, shoulder)

9Listed Not-Medically-Necessary Sites

1External criteria referenced (InterQual)

Coverage Summary

This UnitedHealthcare Community Plan (Idaho) coverage policy addresses Manipulation Under Anesthesia (MUA), a non‑invasive procedure combining manual manipulation with an anesthetic for individuals unable to tolerate manual procedures due to pain, spasm, contracture, or guarding. The policy scope is the UnitedHealthcare Community Plan medical policy applicable to the state of Idaho (including Idaho Medicaid Plus) and defines medical necessity and noncoverage by joint/site with related procedure and diagnosis codes.

Medical-Necessity Criteria

Medically Necessary (Proven) Indications

MUA is proven and medically necessary for:

Knee - Arthrofibrosis following TKA, knee surgery, or fracture: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder - Adhesive capsulitis (frozen shoulder) when InterQual criteria met: 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
For shoulder MUA, providers must document adherence to InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder

ref_symlink_targets__deprecated__DO_NOT_USE__EXPERIMENTAL__v1__refs_only__SAFE_PLACEHOLDER__ignore_me__do_not_use__v1__deprecated_ref_field__IGNORE__v1_ref_field_only__DO_NOT_USE__PLEASE_IGNORE_THIS_FIELD___ref_b1_0__DO_NOT_REMOVE__KEEP_FOR_BACK_COMPATIBILITY___THIS_FIELD_IS_DEPRECATED_AND_SHOULD_BE_IGNORED___v1_ref_b1_0__deprecated_field_do_not_use__ref_b1_0__deprecated_field_placeholder__ref_b1_0__deprecated_keep_intact_for_validation_only__ref_b1_0__deprecated_last_line___ref_b1_0__deprecated___ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0__deprecated__ref_b1_0

title": "Medically Necessary (Proven) Indications

ref": "b1_0

nodes_raw__do_not_use__for_validation_only__KEEP_FIELD__ignore_in_consumption__deprecated__v1__nodes_b1_0__do_not_use__placeholder__ignore": null

ref": "b1_0

title": "Medically Necessary (Proven) Indications

ref":

Not Medically Necessary / Unproven Indications

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

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

Explicit Policy Non-applicability / Exclusions

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

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

Provider Actions & Documentation Requirements

Documentation Required

Shoulder MUA requires InterQual criteria documentation

When requesting coverage for shoulder MUA for adhesive capsulitis, providers must document that the case meets the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria and include supporting evidence of adherence to those InterQual criteria in the request.

Documentation Required

Knee indication documentation

For knee MUA to be considered medically necessary, provider documentation must support Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture. Documentation should include the patient history, physical examination findings, and prior rehabilitation attempts demonstrating persistent restricted motion despite nonoperative management.

27570

Coding

HCPCSHCPCS

D7830

Manipulation under anesthesia

CPT - Procedure Codes referencedCPT

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)

ICD-10 Diagnosis Codes referencedICD-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

Clinical Evidence & Definitions

Evidence for knee MUA includes a 2024 multicenter randomized trial (Abdel et al.) showing a mean immediate ROM improvement of 46° after MUA in post‑TKA stiffness, with similar ROM and clinical outcomes between groups at 6 weeks and 1 year regardless of an adjunct anti‑inflammatory regimen.

Multiple systematic reviews and meta‑analyses (2018–2024) report that MUA after TKA improves range of motion and patient‑reported outcomes, though study quality and heterogeneity limit certainty; timing (early versus delayed) and complication risks have mixed findings with some analyses suggesting greater gain and fewer complications with earlier MUA.

For the spine, TMJ, toe, and other joints, the literature is limited, low quality, and inconsistent (small case series, retrospective studies, and narrative reviews). Overall evidence is insufficient to support routine use of MUA for spine, TMJ, ankle, hip, wrist, finger, pelvis, or toe procedures.

Arthrofibrosis: A complication of injury or trauma where an excessive scar‑tissue response leads to painful restriction of joint motion, with scar tissue forming within the joint and surrounding soft tissues and persisting despite rehabilitation exercises and stretches.

Manipulation under anesthesia (MUA): A non‑invasive procedure combining manual manipulation of a joint or spine with an anesthetic to permit stretching and breaking of adhesions and scar tissue when pain or guarding limit awake manipulation.

Spinal manipulation under anesthesia (SMUA): Spinal manipulation and stretching performed after administration of an anesthetic; proposed to break adhesions within the spinal column but lacking consistent high‑quality evidence of safety or efficacy.

Policy note: Shoulder MUA for adhesive capsulitis requires meeting InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria for medical necessity.

OpenPayer