Medical Policy: 08.01.20
Original Effective Date: April 2012
Reviewed: January 2016
Revised: January 2016
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed with the patient receives anesthesia (usually general anesthesia or moderate sedation). Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft tissue adhesions with less force than would be required to overcome patient resistance or apprehension. MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to treat (reduce) fractures (e.g., vertebral, long bones) and dislocations.
MUA has been proposed as a treatment modality for acute and chronic pain conditions, when standard care, including manipulation, and other conservative measures have been unsuccessful. When utilized for pain management, MUA treatment typically consists of consecutive daily treatment sessions, (generally one to five sessions, with three being the average), followed by additional outpatient sessions and may or may not be accompanied by steroid injections. During the procedure, manipulation of various joints, including the spine, may be performed as part of the overall therapy plan.
Evidence in the medical literature evaluating the use of MUA for management of pain conditions involving one or more (i.e., multiple joints, whole body MUA) of other major joints such as the hip, ankle, toe, elbow, and wrist, is lacking. Due to insufficient evidence conclusions cannot be made regarding the clinical utility or safety and efficacy of MUA involving other single or multiple joints for pain management.
Manipulation of the Knee and Manipulation of the Shoulder
Knee - Manipulation of the knee under anesthesia is medically necessary when performed to treat significant arthrofibrosis of the knee. Following total knee arthroplasty, knee surgery, or fracture in persons having less than 90 degree range of motion, six or more weeks status post-surgery or traumatic event.
Shoulder - Manipulation of the shoulder under anesthesia is medically necessary when performed to treat adhesive capsulitis of the shoulder. When there is failure of conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy.
Per the American Academy of Orthopedic Surgeons and The Arthroscopy Association of North America: Manipulation under anesthesia is included in all arthroscopy procedures and not a separate procedure. Therefore, the separate billing of manipulation under anesthesia during the surgical procedure will be denied as not medically necessary.
Manipulation of the knee and shoulder will be denied as investigational when reported for any other conditions.
Manipulation of anesthesia for the pelvic ring will only be considered medically necessary for pelvic ring fracture, dislocation, diastasis or subluxation. All other conditions, or reasons for manipulation, will be considered investigational.
Serial treatment sessions (i.e., treatments of the same bone/joint provided subsequently over a period of time) are not in accordance with generally accepted standards of medical practice and are therefore not medically necessary.
Manipulation Under Anesthesia - Spine
The following treatments of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain are considered investigational:
- spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia
- spinal manipulation under joint anesthesia
- spinal manipulation after epidural anesthesia and corticosteroid injection
Manipulation under anesthesia involving multiple body joints or other major body joints (ankle, elbow, finger, hip, wrist, temporomandibular) is considered investigational for treatment of all indications, including but not limited to:
- pain, contractures, stiffness, arthritis
Scientific evidence regarding manipulation under anesthesia, spinal manipulation with joint anesthesia, spinal manipulation, and other body joints after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. The evidence is insufficient to determine whether MUA improves health outcomes.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 22505 Manipulation of spine requiring anesthesia, any region
- 00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine
- 27860 Manipulation of ankle under general anesthesia
- 24300 Manipulation, elbow, under anesthesia
- 27275 Manipulation, hip joint, requiring general anesthesia
- 25259 Manipulation, wrist, under anesthesia
- 26340 Manipulation, finger joint, under anesthesia, each joint
- 23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
- 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)
- 27194 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia
- Dagenais S, Mayer J, Wooley JR et al. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J 2008; 8(1):142-9.
- West DT, Mathews RS, Miller MJ et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999; 22(5):299-308.
- Kohlbeck FJ, Haldeman S, Hurwitz EL et al. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther 2005; 28(4):245-52.
- Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25(8): E8-E17.
- Dougherty P. Bajwa S, Burke J et al. Spinal manipulation post epidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther 2004; 27(7):449-56.
- ECRI Institute. Hotline report [database online]. Plymouth Meeting (PA): ECRI Institute. Manipulation under anesthesia of non-spinal body joints. June 2011.
- National Academy of Manipulation Under Anesthesia Physicians (NAMUAP). National Guidelines. Accessed March 22, 2012.
- Yeoh D, Nicolaou N, Goddard R, Manipulation under anesthesia post total knee replacement: long term follow up. Knee. 2012; 19(4): 329-331.
- American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. American Academy of Osteopathy Journal 2005; 15(2):26-27.
- Gordon et al. Chiropractic and Manual Therapies 2014, 22:7.
- Evans KN, Lewandowski L et al. Outcomes of manipulation under anesthesia versus surgical management of combat-related arthrofibrosis of the knee. J Surg Orthop 2013 22(1):36-41
- Gordon, R. Cremata, E. Hawk, C. Guidelines for the practice and performance of manipulation under anesthesia, Chiropr Man Therap. 2014 Feb 3;22(1):7. doi: 10.1186/2045-709X-22-7.
- American Academy of Orthopedic Surgeons, coding bulletin. Available at: http://www2.aaos.org/bulletin/aug05/coding.asp
- Arthroscopy Association of America, frequently used codes. Availble at: http://www.aana.org/practicemanagement/frequentlyaskedcodingquestions
- Sean E. Fitzsimmons, MD, Edward A. Vazquez, BS, and Michael J. Bronson, MD, “How to Treat the Stiff Total Knee Arthroplasty?: A Systematic Review” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835585/
Date Reason Action
April 2012 Literature review New policy
April 2013 Annual review Policy revised
March 2014 Annual review Policy revised
February 2015 Annual review Policy revised
January 2016 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.