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
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:
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.
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.