RetiredUnitedHealthcarePolicy CS075LA.P

Manipulation Under Anesthesia La Cs

State-specific UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applicable only to Louisiana members; defines covered indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis when InterQual criteria met), lists noncovered/unproven indications, applicable CPT/CPT-like codes and ICD-10 diagnosis codes, and references evidence and guideline sources. Policy was retired effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia La Cs

Policy CodePolicy CS075LA.P

Change TypeRetired

Effective DateJun 1, 2025

Next Review Date

Key ActionFor shoulder adhesive capsulitis, document and apply InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria to determine medical necessity.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

06/01/2025 supporting information updated: Clinical Evidence and References sections updated and previous policy archived.

2Primary Covered Joints

9Unproven/Not Covered Regions

1State-specific (LA)

Coverage Summary

State-specific UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applicable only to Louisiana members. The policy defines covered indications as knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture and shoulder joint for adhesive capsulitis (frozen shoulder) when InterQual clinical criteria are met. It lists multiple noncovered or unproven indications (including ankle, finger, hip, pelvis, spine, TMJ, toe, and wrist), provides an applicable CPT/CPT-like and ICD-10 diagnosis code reference list, and summarizes evidence and guideline sources supporting these positions. The policy number is CS075LA.P.

Note: This policy status is RETIRED. The policy was retired effective April 1, 2026 and Louisiana plan membership was disenrolled on that date. The prior effective period was June 1, 2025 - March 31, 2026.

Key Facts

Policy numberCS075LA.P

Effective date2025-06-01

Last review date2026-04-01

StatusRETIRED

Primary covered joints2

Medical Necessity / Coverage Criteria

Medically Necessary (Covered)

MUA 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; clinician to refer to InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity clinical coverage criteria.

Not Medically Necessary / Unproven

MUA is unproven and not medically necessary for all other conditions (whether single or serial manipulations) due to insufficient evidence of efficacy, 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 (TMJ)
Toe
Wrist

Exclusions / Not Applicable

This policy does not apply to the following procedures or circumstances:

ALL of the following

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

Relevant Procedure and Diagnosis Codes

Applicable Procedure Codes (reference list)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).

CPT-like / D-codemixed

D7830

Manipulation under anesthesia

Codes Not on State Fee Schedule (asterisked in policy)mixed

22505	Manipulation of spine requiring anesthesia, any region. (asterisked - not on LA Medicaid Fee Schedule)
D7830	Manipulation under anesthesia. (asterisked - not on LA Medicaid Fee Schedule)

Relevant ICD-10 Diagnosis Codes (reference)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.

Provider Actions / Billing Considerations

Documentation Required

Use InterQual for Shoulder MUA

For shoulder adhesive capsulitis (frozen shoulder), clinicians must document and apply the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria to determine medical necessity for MUA.

Billing Rule

State Fee Schedule Caveat

Codes marked with an asterisk in this policy are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the Louisiana Medicaid Program. Verify the state fee schedule before billing.

22505
D7830

Documentation Required

Apply Contractual/Federal/State Requirements

When determining coverage for MUA, reference and follow any applicable federal, state, or contractual requirements, which govern in the event of a conflict with this standard policy.

Background and Supporting Evidence

Manipulation under anesthesia (MUA) combines manual manipulation of a joint or the spine with anesthetic techniques (which may include general anesthesia, sedation, local injection, or other agents) to overcome pain, spasm, muscle contracture, or guarding so that specific manipulations, passive stretches, and maneuvers can break up adhesions and scar tissue and improve range of motion.

Clinical evidence supports the use of MUA for the knee in the setting of arthrofibrosis after total knee arthroplasty or other knee surgery or fracture, with randomized and systematic-review data showing immediate and sustained improvements in range of motion (for example, a 2024 multicenter randomized trial reported an immediate mean ROM improvement of 46° after MUA) and systematic reviews/meta-analyses showing clinically significant ROM gains especially when performed within 12 weeks post-operatively. Systematic reviews also identify rates and risk factors for MUA after procedures such as ACL reconstruction.

For the shoulder, MUA for adhesive capsulitis is supported when medical necessity criteria in the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder are met; clinicians should refer to InterQual for the specific clinical coverage criteria.

Evidence for MUA of other joints (including ankle, hip, toe, wrist, TMJ) and for spinal MUA/medication-assisted manipulation is limited, inconsistent, and of low or methodologically weak quality. Published studies for spine and TMJ show small samples, lack of controls, and inconsistent outcomes, and major guideline groups have not supported routine use for low back pain; therefore MUA for these other indications is considered unproven/not medically necessary per the policy.

Evidence	Summary
Abdel et al. 2024 randomized trial	Multicenter RCT of 124 post-TKA patients with stiffness; MUA produced an immediate mean ROM improvement of 46° (pre-MUA ROM 72–118° to immediate post-MUA); no difference in ROM or clinical outcomes between MUA+anti‑inflammatory regimen and MUA+PT alone at 6 weeks and 1 year.
Hopper et al. 2024 systematic review	Systematic review of ACL reconstruction cohorts (333,876 ACLRs) found 1.45% underwent subsequent MUA or lysis of adhesions; identified risk factors for arthrofibrosis requiring MUA/LOA (female sex, older age, earlier surgery, anticoagulant use other than aspirin, concomitant meniscal repair).
Systematic reviews/meta-analyses (multiple, 2018–2024) summarizing knee outcomes	Multiple systematic reviews and meta-analyses (e.g., Gu 2018; Haffar 2022; Akhtar 2024) report clinically significant ROM gains after knee MUA, best outcomes when performed within 12 weeks post-op; early MUA associated with greater mean gain in flexion and lower complication/revision rates versus delayed MUA, though study heterogeneity and low quality limit conclusions.
Additional knee case-series and cohort evidence (selected)	Case series and cohort studies (e.g., Frackler 2022 review of LOA+MUA; Grace 2023; Fabricant 2018; Pierce 2017; Tille 2024) consistently show ROM improvement after knee MUA and low complication rates, but many studies lack randomized controls and have methodological limitations.
Evidence for other joints and spine	Narrative reviews and small studies report limited, inconsistent, or low-quality evidence for MUA in spine, TMJ, toe, ankle, hip, wrist, finger, and pelvis; major reviews and guideline bodies conclude insufficient evidence of long-term safety/efficacy for spinal MUA and other non-knee indications.

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 tissue spaces and persisting despite rehabilitation exercises and stretches.

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