CurrentUnitedHealthcarePolicy CS075NE.U

Manipulation Under Anesthesia (for Nebraska Only)

UnitedHealthcare medical policy for Manipulation Under Anesthesia (MUA) that applies only to Nebraska members, defining when MUA is proven/medically necessary (knee arthrofibrosis after TKA/surgery/fracture; shoulder adhesive capsulitis meeting InterQual criteria), and listing joints/uses considered unproven/not medically necessary and exclusions. Includes applicable CPT/HCPCS/ICD-10 codes and supporting evidence summary.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia (for Nebraska Only)

Policy CodePolicy CS075NE.U

Change TypeRevised definition; updated evidence/references; archived prior version

Effective DateMarch 1, 2026

Next Review Date

Key ActionObtain and document required prior authorization and, for shoulder MUA, reference and document compliance with the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder criteria when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections; archived previous policy version CS075NE.T

2Covered Joint Indications (knee, shoulder)

9Unproven / Not Medically Necessary joints

1State-specific (Nebraska)

Coverage Summary

UnitedHealthcare's Manipulation Under Anesthesia (MUA) medical policy applies only to Nebraska members and takes a mixed coverage stance: certain indications are considered proven/medically necessary while many other joints/uses are unproven or not medically necessary.

Policy NumberCS075NE.U

Effective Date2026-03-01

Last Review2026-03-01

ScopeNebraska only

Covered Joint IndicationsKnee (arthrofibrosis), Shoulder (adhesive capsulitis meeting InterQual criteria)

Medical Necessity Criteria

Medically Necessary (Proven) Indications

Manipulation under anesthesia is proven and medically necessary when the following specific joint conditions are met:

ANY of the following

Knee arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder adhesive capsulitis: 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
Providers must reference and document compliance with InterQual criteria when requesting coverage.

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:

Unproven/Not medically necessary joints/conditions

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

Exclusions / Not Covered Scenarios

This policy does not apply to the following specific situations:

Exclusions

Post-Xiaflex finger manipulation: Manipulation of the finger on the day following injection of collagenase clostridium histolyticum (Xiaflex®) to treat Dupuytren contracture
Closed reductions: Closed reduction of a fracture or joint dislocation unless specified
Elbow arthrofibrosis: Elbow joint for Arthrofibrosis following elbow surgery or fracture

Provider Actions / Prior Authorization & Documentation

Prior Authorization

Prior authorization may be required as per benefit plan

Policy notes that UnitedHealthcare may use third-party tools (InterQual) to assist in administering benefits and that benefit coverage is determined by federal, state, or contractual requirements—providers should obtain required prior authorization per the member's plan and local/state rules.

Obtain prior authorization per member plan/local rules

Documentation Required

Use InterQual® criteria for shoulder MUA

For shoulder adhesive capsulitis, the policy requires meeting InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical coverage criteria; providers must reference and document compliance with InterQual criteria when requesting coverage.

Attach InterQual criteria documentation to request

Documentation Required

Document indication as arthrofibrosis for knee MUA

For manipulation of the knee (CPT 27570) to be covered, providers must document that the indication is arthrofibrosis following total knee arthroplasty, knee surgery, or fracture.

27570

Coding (Informational)

Referenced Procedure CPT codes (informational 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 HCPCS code (informational)HCPCS

D7830

Manipulation under anesthesia

Referenced ICD-10 diagnosis codes related to Knee and Shoulder indications (informational)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

Background & Evidence Summary

Manipulation under anesthesia combines manual joint manipulation with anesthesia to permit breaking adhesions and improving range of motion. The evidence base is strongest for knee arthrofibrosis after total knee arthroplasty or other knee surgery (multiple systematic reviews, retrospective studies, and a randomized trial showing significant immediate ROM gains with MUA) and for shoulder adhesive capsulitis when InterQual clinical criteria are met. Evidence is limited or insufficient for many other joints — including spine, temporomandibular joint, ankle, hip, finger, toe, pelvis, and wrist — and therefore MUA for those indications is considered unproven/not medically necessary.

Key Definitions