Medical Policy: 08.01.20 

Original Effective Date: April 2012 

Reviewed: January 2021 

Revised: January 2021 



This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.


Benefit Application:

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 while 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. MUA of the spine is described as follows: after sedation, a series of mobilization, stretching, and traction procedures to the spine and lower extremities are performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand, while the upper torso and lower extremities are stabilized. Spinal manipulative therapy may also be applied to the thoracolumbar or cervical area when necessary to address low back pain.


MUA takes 15 to 20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners recommend performing the procedure on three or more consecutive days for best results (serial manipulation). Care after MUA may include four to eight weeks of active rehabilitation with manual therapy, including spinal manipulative therapy and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal (facet) and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia) and after epidural injection of corticosteroid and local anesthetic (manipulation post-epidural injection). Spinal MUA has also been combined with other joint manipulation during multiple sessions. Together, these therapies may also be referred to as medicine-assisted manipulation.


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. Peer-reviewed literature finds retrospective chart reviews, small sample sizes and single case series. There are no controlled studies or any studies reporting long-term follow-up with outcomes. 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.


Practice Guidelines and Position Statements

American Academy of Osteopathy

The American Academy of Osteopathy published a consensus statement on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. The Academy stated that MUA "may be appropriate in cases of restrictions and abnormalities of function. These include recurrent muscle spasm, range of motion restrictions, persistent pain secondary to injury and/or repetitive motion trauma". "In general, MUA is limited to patients who have somatic dysfunction which:

  1. has failed to respond to conservative treatment in the office or hospital that has included the use of OMT [osteopathic manipulative therapy], physical therapy and medication, and/or
  2. is so severe that muscle relaxant medication, anti-inflammatory medication or analgesic medications are of little benefit, and/or
  3. results in biomechanical impairment which may be alleviated with use of the procedure".


Prior Approval:

Not applicable.



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, when all of the following apply:
    • following total knee arthroplasty, knee surgery, or fracture AND
    • There is less than 90 degrees range of motion in the affected knee AND
    • It is six or more weeks status post-surgery or traumatic event AND
    • Physical therapy has failed to improve range of motion at or equal to 90 degrees.
  • Shoulder - Manipulation of the shoulder under anesthesia is medically necessary when performed to treat adhesive capsulitis of the shoulder, when all of the following apply:
    • Reduction in ROM of at least 50% (prior to injury/surgery) AND
    • Conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy has failed to continuously improve range of motion (after 6 weeks of continuous therapy) AND
    • If surgery or trauma has occured: It is six or more weeks status post-surgery or traumatic event


Manipulation of the knee and shoulder will be denied as investigational when reported for any other conditions or scenario.


During arthroscopy procedures

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.


Serial Treatment Sessions

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:

  • Chronic Fixed Contractures
  • Neck Pain
  • Muscle Spasm
  • Back Pain and Stiffness
  • Chronic Pain
  • Migraines


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.


Documentation Requirements

The medical record should include the following documentation:


  • Failure of condition to respond to conservative therapy, i.e., physical therapy and joint injections; AND
  • Evidence of decreased range of motion with measurements; AND
  • Length of time that the individual has been symptomatic, including date of surgery or traumatic event if applicable.


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)


Selected References:

  • 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.
  • Arthroscopy Association of America, frequently used codes
  • Sean E. Fitzsimmons, MD, Edward A. Vazquez, BS, and Michael J. Bronson, MD, “How to Treat the Stiff Total Knee Arthroplasty?: A Systematic Review
  • Vanlommel L, Luyckx T, Vercruysse G, et al. Predictors of outcome after manipulation under anaesthesia in patients with a stiff total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016 Dec 29 [Epub ahead of print].
  • American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. AAO J. Jun 2005;15(2):26-27.
  • Choi, H., Siliski, J., et al. How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty? Int Orthop. 2014 Aug;38(8):1641-5. doi: 10.1007/s00264-014-2421-z. Epub 2014 Jul 4.
  • Su YD, Lee TC, Lin YC, Chen SK. Arthroscopic release for frozen shoulder: Does the timing of intervention and diabetes affect outcome? PLoS One. 2019 Nov 11;14(11):e0224986. doi: 10.1371/journal.pone.0224986. eCollection 2019.
  • Rotman D, Factor S, Schermann H, Kadar A, Atlan F, Pritsch T, Rosenblatt Y. Manipulation under anesthesia for the postsurgical stiff elbow: a case series and review of literature. Eur J Orthop Surg Traumatol. 2019 Jul 6.
  • Viveen J, Doornberg JN, van den Bekerom MPJ. Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness: Should We Really? Journal Of Orthopaedic Trauma. 2018;32(12):e497-e498. doi:10.1097/BOT.0000000000001339.
  • Spitler CA, Doty DH, Johnson MD, et al. Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness. Journal of Orthopaedic Trauma. 2018 Aug;32(8):e304-e308. DOI: 10.1097/bot.0000000000001222.
  • Yao, D., Bruns, F., Ettinger, S. et al. Manipulation under anesthesia as a therapy option for postoperative knee stiffness: a retrospective matched-pair analysis. Arch Orthop Trauma Surg 140, 785–791 (2020).
  • Kim, D. H., Song, K. S., Min, B. W., Bae, K. C., Lim, Y. J., & Cho, C. H. (2020). Early Clinical Outcomes of Manipulation under Anesthesia for Refractory Adhesive Capsulitis: Comparison with Arthroscopic Capsular Release. Clinics in orthopedic surgery, 12(2), 217–223.


Policy History:

  • January 2021 - Annual Review, Policy Revised
  • February 2020 - Interim Review, Policy Revised
  • January 2020 - Annual Review, Policy Revised
  • January 2019 - Annual Review, Policy Revised
  • July 2018 - Interim Review, Policy Revised
  • January 2018 - Annual Review, Policy Revised
  • January 2017- Annual Review, Policy Renewed
  • January 2016 - Annual Review, Policy Revised
  • February 2015 - Annual Review, Policy Revised
  • March 2014 - Annual Review, Policy Revised
  • April 2013 - Annual Review, Policy Revised
  • April 2012 - 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.


*CPT® is a registered trademark of the American Medical Association.