ModifiedUnitedHealthcarePolicy CS075LA.P

Manipulation Under Anesthesia (for Louisiana Only)

This policy governs coverage and medical necessity determinations for Manipulation Under Anesthesia (MUA) for members in Louisiana, specifying covered indications, non-covered indications, and code references.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Louisiana Only)

Policy CodePolicy CS075LA.P

Change TypeClinical evidence and references updated

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit clinical documentation supporting the covered indication (e.g., knee arthrofibrosis after surgery or shoulder adhesive capsulitis meeting InterQual criteria).

SourceLink

POLICY UPDATE CHANGES

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

1state-specific (LA)

2proven indications

10+unproven/not medically necessary

small samplescommon study limitation

Coverage and Medical Necessity Criteria

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Medically Necessary Indications

Covered when ALL of the following are met:

Knee arthrofibrosis after surgery or fracture: MUA is proven and medically necessary for the knee joint when treating arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.N/A

Document prior rehabilitation and objective range-of-motion (ROM) limitation as applicable; prior authorization required per payer rules.

Shoulder adhesive capsulitis: MUA is proven and medically necessary for the shoulder joint for adhesive capsulitis (frozen shoulder) when the clinical criteria defined by InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder are met.Must meet InterQual criteria

Refer to InterQual for exact clinical inclusion/exclusion and document prior conservative management and objective ROM measures; prior authorization required per payer rules.

Unproven / Not Medically Necessary Indications

Not medically necessary / Unproven for the following joints and indications:

Other joints/conditions: MUA is unproven and not medically necessary for ankle, finger, hip joint (including adhesive capsulitis of the hip), knee conditions other than arthrofibrosis after TKA/knee surgery/fracture, pelvis, spine, temporomandibular joint (TMJ), toe, and wrist (whether single or serial manipulations).N/A

Includes single or serial manipulations; absence of sufficient evidence of efficacy for these sites.

Coverage conclusions by anatomical site

Coverage stance is mixed and depends on joint and available evidence; summarized conclusions from the clinical evidence:

Knee (postoperative arthrofibrosis): Case series and matched-control studies report improvements in ROM after lysis of adhesions (LOA) and MUA and do not indicate increased revision risk after MUA in some cohorts; studies are limited by small samples and lack of randomized controls but report substantial ROM gains and high revision-free rates in select series (e.g., Fabricant et al. 2018 reporting 62% full ROM and 90% revision-free success in a pediatric series; Pierce et al. 2017 matched study found similar revision incidence to controls).study-specific

Evidence supports MUA for postoperative knee arthrofibrosis but is limited by study design and sample size; document objective ROM and prior nonoperative therapy.

Spine (low back/lumbopelvic): Multiple reviews and primary studies conclude evidence is limited or insufficient to support spinal MUA/MAM/SMUA for low back pain; small prospective and retrospective studies report short-term improvements in some patients but are methodologically weak and lack long-term safety data.insufficient evidence

ACOEM and narrative reviews do not recommend spinal MUA/MASM due to poor quality evidence; prior authorization and careful documentation advised if considered.

This policy does not apply to the following specified situations: manipulation of the finger on the day following injection of collagenase clostridium histolyticum (Xiaflex®) for Dupuytren's contracture; closed reduction of a fracture or joint dislocation unless explicitly specified elsewhere in the policy; and elbow joint procedures for arthrofibrosis following elbow surgery or fracture. These exceptions reflect procedure- and timing-specific exclusions where separate guidance or billing rules apply.

No clinical evidence was identified in the reviewed literature to support the use of manipulation under anesthesia (MUA) for the following anatomic sites: ankle, finger, hip, pelvis, or wrist. Because published clinical studies were not found for these joints, MUA for these indications lacks demonstrated efficacy in the evidence base and is not supported by this policy.

MUA performed for conditions beyond the knee arthrofibrosis and shoulder adhesive capsulitis indications listed as medically necessary in this policy is considered unproven and not medically necessary. Specifically, MUA for the ankle, finger, hip (including adhesive capsulitis of the hip), pelvis, spine, temporomandibular joint, toe, wrist, or any knee indication other than arthrofibrosis after total knee arthroplasty, knee surgery, or fracture is categorized as not medically necessary due to insufficient evidence of efficacy.

Spinal applications of MUA (including Spinal Manipulation Under Anesthesia [SMUA], Medication-Assisted Manipulation [MAM], and Medication-Assisted Spinal Manipulation [MASM]) are unsupported by sufficient high-quality evidence. Narrative reviews and guideline statements note methodological weaknesses, small sample sizes, inconsistent controls, and inadequate long-term safety data. Organizations such as ACOEM conclude these spinal MUA approaches are not recommended for acute, subacute, or chronic low back and cervicothoracic pain; therefore spinal MUA/MAM/MASM is considered unsupported by the evidence in this policy.

Applicable Procedure and Diagnosis Codes

Applicable CPT/HCPCS Codes (reference list)mixed

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).
D7830	Manipulation under anesthesia

Applicable ICD-10 Diagnosis Codes (reference list)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

Procedures (informational)mixed

No codes listed

Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization required for covered indications. Submit prior authorization requests with supporting clinical documentation demonstrating that the indication meets medical necessity criteria (for example: knee arthrofibrosis after total knee arthroplasty or shoulder adhesive capsulitis when InterQual criteria are met).

Prior authorization required for knee MUA for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.
Prior authorization required for shoulder MUA for adhesive capsulitis when InterQual® criteria are satisfied.

Prior Authorization

Prior Authorization Recommended for Limited‑Evidence Indications

Prior authorization is recommended (but may not be required) for indications where the evidence is limited or inconsistent (for example, spinal MUA/SMUA/MAM and other limited‑evidence uses). Consider obtaining authorization to support clinical review and payment determination.

Consider prior authorization for spinal MUA/SMUA/MAM and other indications with limited or inconsistent evidence.

Denial Risk

Denial Risk for Non‑Covered Indications

Procedures performed for indications that are not listed as covered (or that do not meet the policy’s medical necessity criteria) are at risk for denial. Claims submitted for non‑covered indications may be denied.

MUA performed for joints or conditions listed as unproven/not medically necessary (e.g., ankle, hip, pelvis, spine, TMJ, wrist, finger, toe, knee conditions other than arthrofibrosis after TKA) are subject to denial.

Denial Risk

Evidence Insufficiency May Trigger Denial

Where high‑quality evidence is insufficient, the service may be denied as not medically necessary. Spinal MUA/SMUA/MAM and other procedures lacking consistent, high‑quality evidence of long‑term safety and effectiveness are particularly likely to be denied.

Insufficient or low‑quality evidence for spinal MUA/SMUA/MAM may lead to denial.
Lack of long‑term safety and efficacy data is a common reason for non‑coverage determinations.

Billing Rule

Coding and Documentation

Include applicable procedure and diagnosis codes on claims and in prior authorization submissions. Codes provided in the policy are for reference and do not guarantee coverage; some codes may be marked with an asterisk indicating state Medicaid fee‑schedule limitations.

Report applicable CPT/HCPCS procedure codes and ICD‑10 diagnosis codes when submitting claims or authorization requests.
Codes noted with an asterisk (*) may not be covered by the State of Louisiana Medicaid Program.

Documentation Required

Required Clinical Documentation

Provide required clinical documentation with prior authorization requests and retain documentation for claims. Documentation should demonstrate the indication, prior conservative care, any prior surgery, objective range‑of‑motion (ROM) measurements (pre‑ and post‑procedure when available), and other relevant clinical findings.

Indication and relevant diagnosis (including laterality where applicable).
History of prior surgery for the affected joint (dates and procedures).
Documentation of conservative therapy attempts and dates (e.g., physical therapy, rehabilitation, spinal manipulation, injections).
Objective ROM measurements prior to the procedure; post‑procedure ROM when available.
Clinical notes describing failure of noninvasive care and rationale for MUA.

Step Therapy

Conservative Therapy Before MUA

Conservative, noninvasive therapies should be attempted prior to MUA where clinically appropriate. Examples include physical therapy, structured rehabilitation programs, targeted injections, oral medications including muscle relaxants, and standard manipulation techniques. Some studies and InterQual criteria require a documented trial of nonoperative management before MUA is performed.

Document dates, providers, and modalities of conservative care (e.g., weeks of physical therapy, home exercise programs, injections).
For spinal indications, ensure an appropriate trial of nonoperative care (e.g., 4–6 weeks of SMT or structured conservative management) is documented prior to consideration of SMUA/MAM.
For shoulder and knee indications, document standard nonoperative treatments attempted prior to authorization and MUA.

Step Therapy

Conservative Therapy Preceding MUA

Some clinical protocols and published studies specifically require prior noninvasive care before proceeding to MUA; include these details in the authorization request to support medical necessity review.

If the treating clinician follows an established protocol (e.g., InterQual, NAMUAP), include protocol adherence documentation.
Note timing between conservative care and the proposed MUA (e.g., duration of PT, dates of injections).

Key Definitions

Arthrofibrosis — definition and clinical context

TermArthrofibrosis

DefinitionA 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.

Clinical contextOccurs after surgery, injury, or fracture and may persist despite rehabilitation; commonly cited indication for MUA in the knee (postoperative arthrofibrosis).

LOA/MUA — definition and typical uses

Acronyms/termsLOA (Lysis of Adhesions) / MUA (Manipulation Under Anesthesia)

DefinitionProcedures combining lysis of adhesions and manipulation under anesthesia intended to improve range of motion after surgery, commonly reported for knee arthrofibrosis and described in case series and cohort studies.

Typical usesReported most often for postoperative knee arthrofibrosis (including pediatric series) and occasionally applied to other joints such as TMJ and toe, though evidence quality varies.

SMUA / MAM / MASM — spinal/manipulation variants and terminology

Acronyms/termsSMUA (Spinal Manipulation Under Anesthesia), MAM (Medication-Assisted Manipulation), MASM (Medication-Assisted Spinal Manipulation)

DefinitionVariations of manipulation under anesthesia applied to the spine that incorporate spinal manipulation techniques with anesthesia and/or medication assistance.

Evidence summaryPublished studies and reviews describe generally weak methodological quality, small sample sizes, and insufficient evidence to support long-term safety and efficacy for spinal indications.

OpenPayer

Manipulation Under Anesthesia (for Louisiana Only)

Coverage and Medical Necessity Criteria

Applicable Procedure and Diagnosis Codes

Authorization, Documentation, and Billing Guidance

Background and Rationale

Key Definitions