CurrentUnitedHealthcarePolicy CS075NJ.P

Manipulation Under Anesthesia Nj Cs

UnitedHealthcare Community Plan medical policy for Manipulation Under Anesthesia (MUA) applicable only to New Jersey members, defining medically necessary indications (knee arthrofibrosis post-TKA/surgery/fracture and shoulder adhesive capsulitis per InterQual), listing noncovered/unproven indications, related exclusions, applicable CPT/CPT-like codes and ICD-10 diagnoses, and providing supporting evidence and policy history.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia Nj Cs

Policy CodePolicy CS075NJ.P

Change TypeRevised definitions & supporting information

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder MUA, reference and meet the InterQual CP criteria when seeking coverage; for knee MUA, document arthrofibrosis following TKA, knee surgery, or fracture in the medical record to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections.

2Indications considered medically necessary

9Joints considered not medically necessary/unproven

11CPT/CPT-like codes listed

Coverage Summary

Policy: UnitedHealthcare Community Plan medical policy CS075NJ.P for Manipulation Under Anesthesia (New Jersey only). Coverage stance: mixed — certain indications are considered medically necessary while others are unproven/not medically necessary. Effective/Last review date: March 1, 2026. See policy CS075NJ.P for full criteria and coding information.

Key statistics and policy dates

Indications considered medically necessary2

Examples of joints considered not medically necessary/unproven9

CPT/CPT-like codes listed11

Effective dateMarch 1, 2026

Last reviewMarch 1, 2026

Medical-Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

ANY of the following

Knee - Arthrofibrosis: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Providers should document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication for knee MUA (see policy documentation).
Shoulder - Adhesive capsulitis: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met
For medical necessity clinical coverage criteria for shoulder MUA, refer to the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder; providers must reference InterQual documentation when seeking coverage.

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Not Medically Necessary / Unproven

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

Unproven/Not Medically Necessary Indications

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

Not Applicable / Policy Exclusions

This policy does not apply to the following:

Exclusions

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

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Coding

CPT / Procedure codes referenced (informational list)CPT

21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (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)

HCPCS / Procedure codeHCPCS

D7830

Manipulation under anesthesia

ICD-10 Diagnosis codes referenced (informational 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

Provider Actions

Documentation Required

Follow InterQual criteria for shoulder MUA

For shoulder adhesive capsulitis, medical necessity coverage requires meeting the InterQual CP: Procedures, Manipulation Under Anesthesia, Shoulder clinical criteria; providers must reference InterQual documentation when seeking coverage.

Documentation Required

Document indication for knee MUA

For knee MUA, providers should document arthrofibrosis following total knee arthroplasty, knee surgery, or fracture as the indication in the medical record to support medical necessity.

CPT 27570

Background and Evidence

Manipulation under anesthesia (MUA) combines manual joint or spinal manipulation with administration of an anesthetic agent to permit more effective release of adhesions and scar tissue in patients who cannot tolerate awake manipulation. Anesthetics used may include general anesthesia, mild sedation, local injection of an anesthetic, oral muscle relaxants, or inhaled agents. Evidence is strongest for treatment of knee arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and there is supporting coverage for some shoulder adhesive capsulitis (frozen shoulder) when InterQual shoulder MUA criteria are met. For spine, TMJ, toe, ankle, hip, wrist, finger, pelvis, and other joints, the evidence is limited, inconsistent, or insufficient to support routine use.

Arthrofibrosis: a 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).

Evidence	Summary
Randomized trial (Abdel et al. 2024)	MUA produced mean immediate ROM improvement of 46° (pre 72° to post 118°); no difference with anti-inflammatory adjuvant at 6 weeks and 1 year.
Systematic reviews/meta-analyses (multiple 2018-2025)	Evidence supports MUA efficacy for postoperative knee stiffness (TKA) with better outcomes when performed early; overall study quality variable and many retrospective designs.
Retrospective and cohort studies (various)	Studies report flexion gains (typical successful gains 27°–33°) after MUA for post-TKA arthrofibrosis; earlier MUA associated with greater gains and fewer complications.
Spine, TMJ, toe, ankle, hip, wrist, finger, pelvis evidence	Limited or insufficient evidence of long-term safety and effectiveness for MUA in these joints; professional guidance (ACOEM) does not recommend MUA/MASM for low back pain.
Definitions / Policy scope	MUA combines manual manipulation with anesthesia to release adhesions; strongest support for knee arthrofibrosis post-TKA/surgery/fracture and for some shoulder adhesive capsulitis per InterQual criteria.

Revision History

03/01/2026revision

Updated definition of 'Arthrofibrosis' and updated Clinical Evidence and References sections. Policy history notes 03/01/2026: Definitions updated; Supporting Information updated; previous policy version archived (CS075NJ.O).

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia Nj Cs

Policy CodePolicy CS075NJ.P

Change TypeRevised definitions & supporting information

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

TMJ: Temporomandibular joint

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title": "Not Medically Necessary / Unproven"

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