CurrentUnitedHealthcarePolicy CS075.U

Manipulation Under Anesthesia

Defines UnitedHealthcare's medical policy for manipulation under anesthesia (MUA) by joint/site, specifying covered indications (knee arthrofibrosis post-TKA/surgery/fracture; shoulder adhesive capsulitis per InterQual criteria), not medically necessary uses (other joints and indications), excluded states for this policy, applicable procedure and diagnosis codes, definitions, background evidence summaries, and instructions for use.

Policy Summary

PayerUnitedHealthcare

PolicyManipulation Under Anesthesia

Policy CodePolicy CS075.U

Change TypeTemplate update; definitions and references updated

Effective DateMar 1, 2026

Next Review Date

Key ActionFor shoulder adhesive capsulitis, providers must reference the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity clinical coverage criteria.

SourceLink

POLICY UPDATE CHANGES

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

Template Update removed content/language pertaining to the state of Louisiana.

Updated definition of 'Arthrofibrosis'.

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

Archived previous policy version CS075.T.

2Primary covered joint indications (knee, shoulder)

9Procedure codes listed for reference

11States with separate policies or exceptions listed

Coverage Summary

Scope: This policy defines UnitedHealthcare's medical coverage approach for Manipulation Under Anesthesia (MUA) by joint/site. Primary covered indications include the knee joint for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture, and the shoulder joint for adhesive capsulitis (frozen shoulder) when the InterQual® criteria for shoulder MUA are met. The policy takes a mixed coverage stance: MUA is considered proven and medically necessary for those knee and specified shoulder indications, and is considered unproven and not medically necessary for other joints and indications due to insufficient evidence.

This policy does not apply in specified states (see state-specific guidance): Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, and Tennessee. Additional exclusions include manipulation of the finger on the day after Xiaflex® injection for Dupuytren contracture, closed reduction of fractures or joint dislocations unless specified, and the elbow joint for arthrofibrosis following elbow surgery or fracture.

Policy dates and scope

Effective dateMarch 1, 2026

Last review dateApril 1, 2026

Policy numberCS075.U

StatusCURRENT

States with separate policies / exclusionsIdaho; Indiana; Kansas; Kentucky; Nebraska; New Jersey; New Mexico; North Carolina; Ohio; Pennsylvania; Tennessee (refer to state-specific policy/guideline)

Medical Necessity Criteria

Medically Necessary

Manipulation under anesthesia is proven and medically necessary for:

Medically Necessary Indications

Knee indication: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Shoulder indication: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met
See InterQual® for specific medical necessity clinical coverage criteria for shoulder MUA.

Evidence Summary: Policy cites evidence supporting efficacy for knee arthrofibrosis post-TKA and references InterQual guidance for shoulder adhesive capsulitis.

Coding (for informational reference)

Procedure Codes referenced (for informational/billing reference)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).

Dental/Other Procedure Codemixed

D7830

Manipulation under anesthesia

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

Provider Actions & Documentation

Documentation Required

Use InterQual® criteria for shoulder MUA coverage determination

For shoulder adhesive capsulitis, providers must reference the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder for medical necessity clinical coverage criteria.

Documentation Required

Confirm indication for knee MUA

Document that knee MUA is for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture to meet medical necessity per policy.

CPT 27570

Background, Evidence, and Definitions

Background: Manipulation under anesthesia combines manual manipulation of a joint or the spine with an anesthetic agent (e.g., general anesthesia, sedation, or local injection) to permit greater range of motion in individuals who cannot tolerate awake manipulation because of pain, spasm, contracture, or guarding. Under anesthesia, specific manipulative techniques, passive stretches, and articular/postural maneuvers are used to break up adhesions and scar tissue around the joint.

Evidence overview (summary): The policy summarizes that MUA has supporting evidence for efficacy in the postoperative knee (arthrofibrosis following TKA) and for the shoulder (adhesive capsulitis) per InterQual® guidance

Evidence summary: For the knee, a multicenter randomized trial (Abdel et al., 2024; n=124) reported an immediate mean ROM gain of 46° after MUA, with no difference between groups at 6 weeks or 1 year when an anti‑inflammatory adjuvant (dexamethasone + celecoxib) was added. Multiple systematic reviews and meta-analyses (Gu 2018; Fackler 2022; Hopper 2024; Akhtar 2024; Patel 2025) support efficacy of MUA for postoperative stiffness after TKA, with the best outcomes reported when MUA is performed within 12 weeks of surgery and with timing and patient risk factors influencing outcomes.

For the spine, TMJ, and other joints, the evidence is limited and of low methodological quality (small samples, weak designs, inconsistent results). Narrative reviews and guideline statements conclude insufficient evidence to support routine use of MUA for low back pain or spinal indications. Professional society guidance (American College of Occupational and Environmental Medicine) does not recommend MUA or medication-assisted spinal manipulation for low back pain because of inadequate evidence of safety and effectiveness.

Evidence	Summary
Knee - randomized trial
Abdel et al. 2024 multicenter RCT (n=124): immediate mean ROM gain ~46° post‑MUA; no sustained difference at 6 weeks or 1 year with/without adjuvant anti‑inflammatory regimen.
Knee - systematic reviews/meta-analyses
Multiple systematic reviews/meta‑analyses (Gu 2018; Fackler 2022; Hopper 2024; Akhtar 2024; Patel 2025) report MUA is efficacious for postoperative knee stiffness (post‑TKA), with best outcomes when performed within ~12 weeks and identified risk factors/timing influence outcomes.
Knee - retrospective/observational studies
Large single‑institution and other case series show typical flexion gains (eg, 24°–33° in successful cases), variable failure rates, and generally improved ROM after MUA or LOA + MUA; limitations include retrospective design and heterogeneity.
Spine
Evidence for spinal MUA/medication‑assisted manipulation is limited, methodologically weak and inconsistent; narrative and systematic reviews and small studies do not support reliable long‑term efficacy.
Temporomandibular joint (TMJ) / Other joints
Evidence for TMJ, ankle, finger, hip, pelvis, toe, wrist is limited, mixed, or from small uncontrolled series; AAOMS provides TMJ guidance for certain indications but overall evidence often inadequate.
References cited (examples)
Key citations include Abdel et al. 2024 (RCT), multiple systematic reviews (Gu 2018; Fackler 2022; Hopper 2024; Akhtar 2024; Patel 2025), and various observational studies and guideline statements (AAOMS, ACOEM).

Revision History

2026-04-01revised

Template Update removed content/language pertaining to the state of Louisiana.

2026-03-01revised

Updated definition of 'Arthrofibrosis'.

2026-03-01revised

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