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 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.
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:
Manipulation of the knee and shoulder will be denied as investigational when reported for any other conditions or scenario.
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 (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.
The following treatments of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain are considered investigational:
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:
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.
The medical record should include the following documentation:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
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.