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Manipulation Under General Anesthesia

Policy History

Last Review

10/16/2019

Effective: 03/12/1998

Next

Review: 02/13/2020

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0204

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

I. Aetna considers spinal manipulation under general

anesthesia (MUA) experimental and investigational.

This procedure has not been established as either safe

or effective for the treatment of musculoskeletal

disorders such as neck and back problems. Critical

issues such as selection criteria, outcome assessments,

and long-term benefits need to be addressed by well-

designed studies before this procedure can be

considered as an essential part of conservative therapy.

In this regard, the Guidelines for Chiropractic Quality

Assurance and Practice Parameters published from the

proceedings of a consensus conference commissioned

by the Congress of Chiropractic State Associations

declared that chiropractic involvement in MUA is a new

area of special interest that needs further investigation.

II. Aetna considers MUA medically necessary for the

following indications:

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A. Arthrofibrosis of knee following total knee arthroplasty,

knee surgery, or fracture (see Appendix); or

B. Chronic, refractory frozen shoulder (adhesive capsulitis)

(see Appendix); or

C. Temporomandibular joint disorders.

III. Aetna considers MUA for injuries of the cruciate

ligaments, of multiple joints, for disorders of other body

joints (e.g., ankle, elbow, finger, hip, pelvis, toe, and

wrist), or for osteoporotic thoracolumbar vertebral

compression fracture experimental and investigational

because there is insufficient evidence to support this

approach.

IV. Aetna considers MUA of the hand/fingers after

collagenase clostridium histolyticum (Xiaflex) injections

for the treatment of Dupuytren's contracture

experimental and investigational.

Note: This policy is not intended to apply to examinations

under anesthesia, or to setting fractures or complete joint

dislocations under anesthesia.

Background

Manipulation under anesthesia (MUA) is a noninvasive

treatment technique used to treat acute and chronic

conditions, including muscular or spinal pain. Under

anesthesia, spastic muscles are believed to relax and pain

sensations diminish, which theoretically may permit joint

manipulation through a full range of motion.

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During manipulation under anesthesia, in addition to the

manipulation, passive stretches and specific articular and

postural kinesthetic maneuvers may be performed in order to

break up fibrous adhesions and scar tissue around the spine

and surrounding tissues.

Spinal manipulation under anesthesia (SMUA) has been used

mostly by osteopaths and to a much lesser degree by

orthopedists to treat spinal dysfunction. This procedure was

typically performed in 1 single session. More recently, some

chiropractors, with the assistance of anesthesiologists, have

also employed this technique to alleviate acute and chronic

neck and back pain.

The rationale for this approach is that fibrotic changes in the

peri-articular and intra-articular soft tissues hinder movement,

and sometimes it is necessary to anesthetize patients to

reduce muscle tone and protective reflex mechanisms so that

the spine can be manipulated effectively. This maneuver

supposedly will break up adhesions within the surrounding

spinal joints and stretch the restricting fibrotic tissue to a length

compatible with motion, thereby, increasing joint function and

reducing pain.

Within the realm of chiropractic, SMUA is generally performed

daily for 1 to 5 consecutive days on an outpatient basis, and is

followed by a post-SMUA rehabilitation regimen, which

entails 1 week of daily manipulation to maintain joint mobility

and avoid re-adhesion of fibrotic tissue. Anesthesia is usually

induced by intravenous Pentothal (sodium thiopental), and

manipulation of the affected joints takes about 7 to 10 minutes.

Although the risks associated with spinal manipulation and

SMUA appear remote, serious complications following lumbar

spinal manipulation, including massive cauda equina

compression and vertebral pedicle fracture have been

reported. For manipulation of the cervical spine, there is an

increased chance of basivertebral and/or vertebral artery

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injury. Additionally, general anesthesia carries a small but

clinically significant risk of anaphylaxis or malignant

hyperpyrexia.

An assessment on SMUA (Kohlbeck and Haldeman, 2002)

concluded that medicine assisted spinal manipulation

therapies have a relatively long history of clinical use and have

been reported in the literature for over 70 years. However,

evidence for the effectiveness of these protocols remains

largely anecdotal, based on case series mimicking many other

surgical and conservative approaches for the treatment of

chronic pain syndromes of musculoskeletal origin. There is,

however, sufficient theoretical basis and positive results from

case series to warrant further controlled trials on these

techniques.

There is a lack of reliable evidence in the peer-reviewed

published medical literature of the effectiveness of spinal

manipulation under anesthesia. Evidence of spinal

manipulation under anesthesia is of low quality, consisting

primarily of case reports and uncontrolled case series.

Limitations of current literature include small sample sizes,

lack of random assignment, and limited evidence of durability.

Other issues include uncertainties in patient selection criteria,

and differences in protocols reported in studies, making

generalizations difficult. Studies have reported on attendant

risks of spinal manipulation (see., e.g., Dan & Saccasan, 1983,

reporting on cases of serious complications after lumbar spinal

manipulation, including massive cauda equina compression

and vertebral pedicle fracture), and the risks of general

anesthesia are well known. Guidelines from the American

College of Occupational and Environmental Medicine (2007,

2008) and the Work Loss Data Institute (2011) state that spinal

manipulation under anesthesia is not recommended.

In a prospective cohort study of 68 chronic low-back pain

(LBP) patients, Kohlbeck et al (2005) measured changes in

pain and disability for LBP patients receiving treatment with

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medication-assisted manipulation (MAM) and compared these

to changes in a group only receiving spinal manipulation

therapy (SMT). Outcomes were measured using the 1998

Version 2.0 American Association of Orthopaedic

Surgeons/Council of Musculoskeletal Specialty

Societies/Council of Spine Societies Outcomes Data Collection

Instruments. The primary outcome variable was change in

pain and disability. All patients received an initial 4- to 6-week

trial of SMT, after which 42 patients received supplemental

intervention with MAM and the remaining 26 patients

continued with SMT. Low back pain and disability measures

favored the MAM group over the SMT-only group at 3 months.

This difference attenuated at 1 year. These investigators

concluded that medication-assisted manipulation appears to

offer some patients increased improvement in LBP and

disability, and stated that further investigation of these

apparent benefits in a randomized clinical trial is warranted.

Colorado Division of Workers' Compensation’s guidelines on

“Low back pain medical treatment” (2014) did not recommend

MUA.

Manipulation under anesthesia has been used for refractory

cases of frozen shoulder (adhesive capsulitis) (Dias et al,

2005). Patients with frozen shoulder may describe chronic

pain symptoms, but primarily complain of stiffness. The loss of

range of motion causes various degrees of impaired function,

including limited reaching (overhead, across the chest, etc)

and limited rotation (unable to scratch the back, put on a coat,

etc). On physical examination, patients with a frozen shoulder

will have at least a 50 % reduction in both active and passive

range of motion (ROM) compared with the unaffected shoulder

(Anderson, 2008). Range of motion is estimated as follows: (i)

the Apley scratch test is used to assess rotation of the

shoulder joint; patients with normal glenohumeral motion

should be able to scratch the midback at the T8 to T10

level; patients with frozen shoulder are not able to scratch

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even the lower back; (ii) the NFL touchdown sign is an active

maneuver used t o assess ROM of the shoulder joint and

the strength of abduction; patients with a frozen shoulder

are unable to fully lift their arm straight overhead; and ( iii)

passive movement of the arm in abduction and e xternal

rotation also is measured; the normal glenohumeral joint

rotates externally to 90 degrees and abducts to 90

degrees. Manipulation under anesthesia is not first-line

therapy for frozen shoulder because, in most cases, frozen

shoulder is a self-limited condition that responds well to

conservative therapy. In addition, MUA can actually aggravate

symptoms in some people, while others may develop a

recurrence of adhesive capsulitis. Less than 10 % of patients

will have long-term problems that require surgery or MUA

(Anderson, 2008; Ogilvie-Harris e t al, 1995).

Patients with frozen shoulder should be advised to limit

overhead positioning, overhead reaching, and lifting during the

acute period. A non-steroidal antiinflammatory drug

(NSAID) may be prescribed for pain control. Exercise is the

treatment of choice during the acute period; up to one-half of

patients with frozen shoulder may be expected to respond to

exercise therapy (van der Windt et al, 1998). Steroid injection

may hasten recovery in persons with frozen shoulder who

have concurrent rotator cuff and bicipital tendonitis (van der

Windt et al, 1998), and the addition of supervised physical

therapy following corticosteroid injection may result in more

rapid improvement than injection alone (Carette et al, 2003).

Glenohumeral intraarticular injection combined with saline

dilation is indicated for patients with greater than 50 % loss of

ROM despite a trial of physical therapy, subacromial injection,

or both (Jacobs et al, 1991).

Referral for surgery is warranted in patients who fail to have an

improvement in ROM by approximately 15 % per month with

the above measures (Anderson, 2008). There are 2 main

surgical approaches: arthroscopic dilation of the glenohumeral

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joint or MUA. The former is now more commonly performed

than the latter. Newer arthroscopic techniques carry out a

controlled capsular release rather than a forceful manipulation

with its resultant uncontrolled tearing and bleeding.

A systematic review in BMJ Clinical Evidence (Speed, 2006)

found that MUA plus intra-articular injection is "likely to be

beneficial" for persons with frozen shoulder. The conclusions

were based upon the results of 2 randomized controlled trials

(RCTs). One RCT (n = 30) found that, in people with adhesive

capsulitis, MUA plus intra-articular hydrocortisone injection

increased recovery rates compared with intra-articular

hydrocortisone injection alone at 3 months (Thomas et al,

1980). Another, weaker RCT (n = 98) found limited evidence

that more people having MUA plus intra-articular saline

injection than having manipulation alone or manipulation plus

intra-articular injection of methylprednisolone had

improvements in ROM, pain relief, and return to normal

activities (Hamdan and Al Essa, 2003). The review noted that

potential adverse effects of MUA of the shoulder include intra-

articular lesions within the glenohumeral joint (Speed, 2006).

In a Cochrane review, Green et al (2000) examined the

effectiveness of common interventions for shoulder pain.

Intervention of interest included NSAIDs, intra-articular or

subacromial glucocorticosteroid injection, oral

glucocorticosteroid treatment, physiotherapy, MUA,

hydrodilatation, or surgery. The authors concluded that there

is little evidence to support or refute the effectiveness of

common interventions for shoulder pain. They stated that

there is a need for further well-designed clinical trials to

establish a uniform method of defining shoulder disorders and

developing outcome measures which are valid, reliable and

responsive in these study populations.

Quraishi et al (2007) assessed the outcome of MUA and

hydrodilatation as treatments for adhesive capsulitis. A total of

36 patients (38 shoulders) were randomized to receive either

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method, with all patients being treated in stage II of the

disease process. The mean age of the patients was 55.2

years (44 to 70) and the mean duration of symptoms was 33.7

weeks (12 to 76). A total of 18 shoulders (17 patients)

received MUA and 20 (19 patients) received hydrodilatation.

There were 3 insulin-dependent diabetics in each group. The

mean visual analog score (VAS) in the MUA group was 5.7 (3

to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at 2

months (paired t-test p = 0.02), and 2.7 (0 to 9; n = 16) at 6

months (paired t-test, p = 0.0006). The mean score in the

hydrodilatation group was 6.1 (4 to 10; n = 20) before

treatment, 2.4 (0 to 8; n = 18) at 2 months (paired t-test, p =

0.001), and 1.7 (0 to 7; n = 18) at 6 months (paired t-test, p =

0.0006). The VAS in the hydrodilatation group were

significantly better than those in the MUA group over the

6-month follow-up period (p < 0.0001). The mean Constant

score in those manipulated was 36 (26 to 66) before

treatment, 58.5 (24 to 90) at 2 months (paired t-test, p = 0.001)

and 59.5 (23 to 85) at 6 months (paired t-test, p = 0.0006). In

the hydrodilatation group it was 28.8 (18 to 55) before

treatment, 57.4 (17 to 80) at 2 months (paired t-test, p =

0.0004) and 65.9 (28 to 92) at 6 months (paired t-test, p =

0.0005). The Constant scores in the hydrodilatation group

were significantly better than those in the MUA group over the

6-month period of follow-up (p = 0.02). The ROM improved in

all patients over the 6 months, but was not significantly

different between the groups. At the final follow-up, 94 % of

patients (17 of 18) were satisfied or very satisfied after

hydrodilatation compared with 81 % (13 of 16) of those who

received MUA. Most patients were treated successfully, but

those undergoing hydrodilatation did better than those who

underwent MUA.

Kivimäki and colleagues (2007) examined the effect of MUA in

patients with frozen shoulder. A blinded randomized trial with

a 1-year follow-up was performed at 3 referral hospitals. A

total of 125 patients with clinically verified frozen shoulder

were randomly assigned to the manipulation group (n = 65) or

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control group (n = 60). Both the intervention group and the

control group were instructed in specific therapeutic exercises

by physiotherapists. Clinical data were gathered at baseline

and at 6 weeks and 3, 6, and 12 months after randomization.

The 2 groups did not differ at any time of the follow-up in terms

of shoulder pain or working ability. Small differences in

the ROM were detected favoring the manipulation group.

Perceived shoulder pain decreased during follow-up equally in

the 2 groups, and at 1 year after randomization, only slight

pain remained. Manipulation under anesthesia does not add

effectiveness to an exercise program performed by patients.

Flannery et al (2007) examined the influence of timing of MUA

for adhesive capsulitis of the shoulder on the long-term

outcome. A total of 180 consecutive patients with a diagnosis

of adhesive capsulitis according to Codman's criteria were

selected from a shoulder surgery database; 145 were

available for follow-up after a mean period of 62 months

(range of 12 to 125). All patients underwent MUA with intra-

articular steroid injection. A statistically significant

improvement in range of movement, function (Oxford Shoulder

Score) (OSS) and VAS was obtained following manipulation.

Ninety percent of the 145 patients who successfully completed

the study were satisfied with the procedure; 89 % indicated

that they would choose the same procedure again if the same

problem arose in the opposite shoulder. Eighty-three percent

of the patients had MUA performed less than 9 months from

onset of symptoms (early MUA). The remainder had MUA

performed after 9 to 40 months (late MUA). Patients who had

early intervention had a significantly better Oxford Shoulder

Score at final follow-up; mobility and pain were also letter than

in the late MUA group, but not significantly.

Manipulation under anesthesia has also been used to treat

fibroarthrosis following total knee replacement. Following total

knee arthroplasty, some patients who fail to achieve greater

than 90 degrees of flexion in the early peri-operative period

may be considered candidates for MUA of the knee.

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Manipulation under anesthesia is indicated in total knee

arthroplasty having less than 90 degrees ROM 4 to 12 weeks

following surgery, with no progression or regression in ROM

(Pariente et al, 2006; Magit,et al, 2007).

Keating et al (2007) assessed the outcomes of manipulation

following total knee arthroplasty. A total of 113 knees in 90

patients underwent manipulation for post-operative flexion of

greater than or equal to 90 degrees at a mean of 10 weeks

after surgery. Eighty-one (90 %) of the 90 patients achieved

improvement of ultimate knee flexion following manipulation.

The average flexion was 102 degrees prior to total knee

arthroplasty, 111 degrees following skin closure, and 70

degrees before manipulation. The average improvement in

flexion from the measurement made before manipulation to

that recorded at the 5-year follow-up was 35 degrees (p <

0.0001). The investigators reported that there was no

significant difference in the mean improvement in flexion when

patients who had manipulation within 12 weeks post-

operatively were compared with those who had manipulation

more than 12 weeks post-operatively. Patients who eventually

underwent manipulation had significantly lower pre-operative

Knee Society pain scores (more pain) than those who had not

had manipulation (p = 0.0027). The investigators concluded

that manipulation generally increases ultimate flexion following

total knee arthroplasty. They noted that patients with severe

pre-operative pain are more likely to require manipulation.

Available evidence for MUA for temporomandibular joint

syndrome is limited to small, uncontrolled studies with limited

follow-up. Foster et al (2000) conducted an uncontrolled

prospective study of manipulation of the temporomandibular

joint under anesthesia. The investigators reported that, of the

55 patients invited to participate in this study, 15 improved, 15

did not, 6 showed partial improvement, and 19 were not

treated. The median pre-treatment opening was 20 mm

(range of 13 to 27). Among those who improved after

manipulation, the median opening after treatment was 38 mm

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(range of 35 to 56). The investigators reported that some of

those who improved experienced a return of TMJ clicking but

not of joint or muscle tenderness.

There is a paucity of evidence supporting the use of MUA for

the treatment of disorders of other body joints such as the

hip, ankle, knee, and wrist.

The National Academy of Manipulation Under Anesthesia

Physicians' protocols for performing serial MUA (2002) stated

that if the patient regains 80 % or more of normal

biomechanical function during the first procedure and retains

at least 80 % of functional improvement during post MUA

evaluation, then serial MUA is usually unnecessary if post

MUA therapy and rehabilitation is performed.

Araghi et al (2010) have used a technique of elbow

examination (manipulation) under anesthesia in select patients

after surgical release to assess the smoothness of the

articulation, evaluate stability, and to stretch the flexion and

rotation arcs. The study comprised 51 consecutive patients

who underwent an examination under anesthesia between

January of 1996 and December of 2001. The examination

occurred a mean of 40 days after surgery. Forty-four patients

with a minimum of 12 months follow-up revealed a mean pre-

examination arc of 33 degrees, which improved to 73 degrees

at the final assessment. Three patients had no appreciable

change (less than 10 degrees ) in the total arc, and 1 patient

lost motion. Four patients underwent a second examination

under anesthesia at a mean of 119 days after the first

examination. The average pre-examination arc of 40 degrees

increased to 78 degrees at the final assessment (mean

improvement of 38 degrees). The only complication was

worsening of ulnar paresthesias in 3 patients; with 2 resolving

spontaneously, and 1 requiring anterior ulnar nerve

transposition. The authors concluded that examination

(manipulation) under anesthesia can be a valuable adjunctive

procedure to help regain the motion obtained at the time of

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surgical release. Moreover, they stated that because this was

not a controlled series, additional studies might be conducted

to refine those not benefiting from this procedure.

The U.S. Food and Drug Administration's labeling of Xiaflex

(collagenase Clostridium histolyticum) for Dupuytren's

contracture requires a finger extension procedure for

persistent palpable cord, which is described in the labeling as

a passive extension of a finger for 20 seconds. Local

anesthetic may be used with this procedure. The finger

extension procedure may be repeated a 2nd or 3rd time at 5-

to 10-min intervals. However, manipulation under general

anesthesia is not necessary to accomplish this procedure.

Xiong and colleagues (1998) stated that manipulation under

anesthesia (MUA) is an important method to reduce cervical

spinal dislocations in the acute stage. Causes of failure have

not been clearly identified and neurological complications can

be the major concern. All cervical dislocations have been

traditionally treated by MUA in the Christchurch Spinal Injuries

Unit as the primary treatment. These researchers reviewed all

31 patients treated from 1991 to 1995, with detailed

documentation of neurological progression and final outcome.

Three patterns were identified: bilateral dislocation, uni-facet

dislocation, and fracture dislocation. Most of the dislocations

(74 %) were successfully reduced by manipulation alone with

minimum complications. The remaining 26 % patients

required open reduction. The predominant causes of failure of

reduction by manipulation were co-existing fractures. The

success rate of reduction by manipulation was 90 % for pure bi-

facet and uni-facet dislocations, but was only 22 % for the

fracture dislocations. The authors concluded that MUA is a

safe and effective procedure for pure cervical spinal

dislocations. Fractures related to the dislocation should be

identified early and open reduction be considered.

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Also, an UpToDate review on “Evaluation and acute

management of cervical spinal column injuries in adults” (Kaji

and Hockberger, 2013) does not mention the use of MUA as a

management tool.

The Washington State Department of Labor and Industries’

guideline on “Shoulder conditions diagnosis and

treatment” (2013) recommended MUA for arthroscopic

capsular release when conventional x-rays do not show bone

pathology that can explain the loss of motion and patients

have tried and failed 12 weeks of conservative care (including

at least active assisted range of motion and home-based

exercises).

Post-Traumatic Elbow Stiffness

In a retrospective, case-series study, Spitler and colleagues

(2018) evaluated the safety and efficacy of MUA for post-

traumatic elbow stiffness. These researchers carried out a

chart review of 45 patients over a 10-year period treated with

MUA for post-traumatic elbow stiffness after elbow injuries

treated both operatively and non-operatively. Main outcome

measures were change in total flexion arc pre- to post-

manipulation; time to manipulation; and complications.

Average time from most recent surgical procedure or date of

injury to MUA was 115 days. Average pre-manipulation flexion

arc was 57.9 degrees; average flexion arc at the final follow-up

was 83.7 degrees. The improvement in elbow flexion arc of

motion was statistically significant (p < 0.001). Post-hoc

analysis of the data revealed 2 distinct groups: 28 patients

who underwent MUA within 3 months of their most recent

surgical procedure (early manipulation), and 17 patients who

underwent MUA after 3 months (late manipulation). Average

improvement in elbow flexion arc in the early MUA group was

38.3 degrees (p < 0.001); improvement in the late MUA group

was 3.1 degree. Comparison of improvement between the

early and late MUA groups found a significant difference (p <

0.001) in mean flexion arc improvement from pre-manipulation

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to post-manipulation, favoring the early group. One patient

had a complication directly attributable to MUA; 19 patients

needed additional procedures on the injured extremity after

MUA. The authors concluded that MUA was a safe and

effective adjunct to improving motion in post-traumatic elbow

stiffness when used within 3 months from the original injury or

time of surgical fixation. After 3 months, MUA did not reliably

increase elbow motion. This was a relatively small (n = 45),

retrospective study; it provided level IV evidence; these

findings need to be validated by well-designed studies.

Appendix

Condition Indications

Knee

arthrofibrosis

MUA is considered medically necessary

arthrofibrosis of knee following total knee

arthroplasty, knee surgery, or fracture in

persons having less than 90 degrees ROM

4 weeks to 6 months after surgery or

trauma.

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Frozen

shoulder

(adhesive

capsulitis)

MUA is considered medically necessary

for chronic, refractory frozen shoulder

(adhesive capsulitis) that meets the

following criteria:

I. Adhesive capsulitis should be

documented by restricted active and

passive glenohumeral and

scapulothoracic motion for at least

1-month duration which has either

reached a plateau or worsened; and

II. Significant reduction in ROM (at

least a 50 % reduction in both active

and passive ROM compared with

the unaffected shoulder); and

III. Causing various degrees of impaired

function, including limited reaching

(e.g., overhead, across the chest)

and limited rotation (e.g., unable to

scratch the back, difficulty putting

on a coat); and

IV. Persons have undergone at least 12

weeks of conservative management,

and have failed to improve,

including analgesics

or corticosteroids, physical therapy

or therapeutic exercises, and

subacromial corticosteroid injection

or hydrodilatation (arthrographic

distension, hydrodilation,

hydroplasty); and

V. Conventional x-rays do not show

bone pathology that can explain the

loss of motion.

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CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

MUA of spine:

CPT codes not covered for indications listed in the CPB (not all-inclusive):

22505 Manipulation of spine requiring anesthesia, any

region

Other CPT codes related to the CPB:

00600 Anesthesia for procedures on cervical spine

and cord; not otherwise specified

00604 Anesthesia for procedures on cervical spine

and cord; procedures with patient in the sitting

position

00620 Anesthesia for procedures on thoracic spine

and cord, not otherwise specified

00625 Anesthesia for procedures on the thoracic spine

and cord, via an anterior transthoracic

approach; not utilizing 1 lung ventilation

00626 Anesthesia for procedures on the thoracic spine

and cord, via an anterior transthoracic

approach; utilizing 1 lung ventilation

00630 Anesthesia for procedures in lumbar region; not

otherwise specified

00632 Anesthesia for procedures in lumbar region;

lumbar sympathectomy

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00635 Anesthesia for procedures in lumbar region;

diagnostic or therapeutic lumbar puncture

00640 Anesthesia for manipulation of the spine or for

closed procedures on the cervical, thoracic, or

lumbar spine

00670 Anesthesia for extensive spine and spinal cord

procedures (eg, spinal instrumentation or

vascular procedures)

01999 Unlisted anesthesia procedure(s)

99152 Moderate sedation services provided by the

same physician or other qualified health care

professional performing the diagnostic or

therapeutic service that the sedation supports,

requiring the presence of an independent

trained observer to assist in the monitoring of

the patient's level of consciousness and

physiological status; initial 15 minutes of

intraservice time, patient age 5 years or older

+99153 each additional 15 minutes intraservice time

(List separately in addition to code for primary

service)

99156 Moderate sedation services provided by a

physician or other qualified health care

professional other than the physician or other

qualified health care professional performing

the diagnostic or therapeutic service that the

sedation supports; initial 15 minutes of




service)

MUA of knee:

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CPT codes covered if selection criteria are met:

27570 Manipulation of knee joint under general

anesthesia (includes application of traction or

other fixation devices)


01320 Anesthesia for all procedures on nerves,

muscles, tendons, fascia, and bursae of knee

and/or popliteal area

01380 Anesthesia for all closed procedures on knee

joint

01382 Anesthesia for diagnostic arthroscopic

procedures of knee joint

01390 Anesthesia for all closed procedures on upper

ends of tibia, fibula, and/or patella













service)

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service)

ICD-10 codes covered if selection criteria are met :

M24.661

-

M24.669

Ankylosis of joint, knee [arthrofibrosis following

total knee arthroplasty]

S72.401+

-

S72.499+

Fracture of lower end of femur

S79.101+

-

S79.199+

Unspecified physeal fracture of lower end of

femur

S82.001+

-

S82.099+

Fracture of patella

S82.101+

-

S82.156+,

S82.191+

-

S82.199+

Fracture of upper end of tibia and other fracture

of upper end of tibia

S82.401+

-

S82.499+

Fracture of fibula

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S83.200+

- S83.32+

Tear of meniscus, current injury and tear of

articular cartilage of knee, current

S89.001+

-

S89.099+

Physeal fracture of upper end of tibia

S89.201+

-

S89.299+

Physeal fracture of upper end of fibula

Z96.651 -

Z96.659

Presence of artificial knee joint [arthrofibrosis

following total knee arthroplasty]

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive) :

S86.001+

-

S86.999+

Injury of muscle, fascia and tendon at lower leg

level

S96.001+

-

S96.999+

Injury of muscle and tendon at ankle and foot

level

MUA of shoulder:


23700 Manipulation under anesthesia, shoulder joint,

including application of fixation apparatus

(dislocation excluded)



muscles, tendons, fascia, and bursae of

shoulder and axilla

01620 Anesthesia for all closed procedures on

humeral head and neck, sternoclavicular joint,

acromioclavicular joint, and shoulder joint

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procedures of shoulder joint

01630 Anesthesia for open or surgical arthroscopic

procedures on humeral head and neck,

sternoclavicular joint, acromioclavicular joint,

and shoulder joint; not otherwise specified













service)










service)

ICD-10 codes covered if selection criteria are met:

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M75.00 -

M75.02

Adhesive capsulitis of shoulder [only if X-rays

do not show bone pathology that can explain

the loss of motion]

MUA of temporomandibular joint:


21073 Manipulation of temporomandibular joint(s)

(TMJ), therapeutic, requiring an anesthesia

service (ie, general or monitored anesthesia

care)


00170 Anesthesia for intraoral procedures, including

biopsy; not otherwise specified

00190 Anesthesia for procedures on facial bones or

skull; not otherwise specified


ICD-10 codes covered if selection criteria are met:

M26.601

- M26.69

Temporomandibular joint disorders

S02.400+

-

S02.413+

Fracture of malar, maxillary and zygoma bones,

unspecified and LeFort fracture

S02.600+

-

S02.69x+

Fracture of mandible

S03.00xA

-

S03.02xS

Dislocation of jaw

MUA of other joints:

CPT codes not covered for indications listed in the CPB (not all inclusive):

Proprietary



24300 Manipulation, elbow, under anesthesia

25259 Manipulation, wrist, under anesthesia

26340 Manipulation, finger joint, under anesthesia,

each joint

26341 Manipulation, palmar fascial cord (ie,

Dupuytren's cord), post enzyme injection (eg,

collagenase), single cord

27198 Closed treatment of posterior pelvic ring

fracture(s), dislocation(s), diastasis or

subluxation of the ilium, sacroiliac joint, and/or

sacrum, with or without anterior pelvic ring

fracture(s) and/or dislocation(s) of the pubic

symphysis and/or superior/inferior rami,

unilateral or bilateral; with manipulation,

requiring more than local anesthesia (ie,

general anesthesia, moderate sedation,

spinal/epidural)

27275 Manipulation, hip joint, requiring general

anesthesia

27860 Manipulation of ankle under general anesthesia

(includes application of traction or other fixation

apparatus


01160 Anesthesia for closed procedures involving

symphysis pubis or sacroiliac joint

01170 Anesthesia for open procedures involving

symphysis pubis or sacroiliac joint

01200 Anesthesia for procedures on bony pelvis

01202 Anesthesia for arthroscopic procedures of hip

joint

Proprietary



01220 Anesthesia for all closed procedures involving

upper two-thirds of femur


muscles, tendons, fascia, and bursae of upper

leg

01462 Anesthesia for all closed procedures on lower

leg, ankle, and foot

01464 Anesthesia for arthroscopic procedures of ankle

and/or foot

01470 Anesthesia for procedures on nerves, muscles,

tendons, and fascia of lower leg, ankle, and

foot; not otherwise specified

01710 Anesthesia for procedures on nerves, muscles,

tendons, fascia, and bursae of upper arm and

elbow; not otherwise specified

01730 Anesthesia for all closed procedures on

humerus and elbow


procedures of elbow joint

01740 Anesthesia for open or surgical arthroscopic

procedures of the elbow; not otherwise

specified


muscles, tendons, fascia, and bursae of

forearm, wrist, and hand

01820 Anesthesia for all closed procedures on radius,

ulna, wrist, or hand bones


procedures on the wrist

Proprietary



01830 Anesthesia for open or surgical

arthroscopic/endoscopic procedures on distal

radius, distal ulna, wrist, or hand joints; not

otherwise specified













service)

Other HCPCS codes related to the CPB:

J0775 Injection, collagenase, clostridium histolyticum,

0.01 mg

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

M00.011

M24.659,

M24.671

M26.59,

M26.70

M72.9,

M75.100

M99.9

Diseases of the musculoskeletal system and

connective tissue [other than those listed as

covered]

Proprietary


The above policy is based on the following references:

1. Guidelines for Chiropractic Quality Assurance and

Practice Parameters: Proceedings of the Mercy Center

Consensus Conference, Burlingame, CA, January 25 -

30, 1992. S Haldeman, et al., eds. Gaithersburg, MD:

Aspen Publishers, Inc.; 1993.

2. Dreyfuss P, Michaelsen M, Horne M. MUJA:

Manipulation under joint anesthesia/analgesia: A

treatment approach for recalcitrant low back pain of

synovial joint origin. J Manipulative Physiol Ther.

1995;18(8):537-546.

3. Davis CG. Chronic cervical spine pain treated with

manipulation under anesthesia. J

Neuromusculoskeletal Syst. 1996;4:102-115.

4. Ben-David B, Raboy M. Manipulation under anesthesia

combined with epidural steroid injection. J

Manipulative Physiol Ther. 1994;17:605-609.

5. Alexander GK. Manipulation under anesthesia of

lumbar post-laminectomy syndrome patients with

epidural fibrosis and recurrent HNP. ACA J Chiro.

1993;June:79-81.

6. Dan NG, Saccasan PA. Serious complications of lumbar

spinal manipulation. Med J Aust. 1983;2(12):672-673.

7. Hughes BL. Management of cervical disk syndrome

utilizing manipulation under anesthesia. J Manipulative

Physiol Ther. 1993;16:174-181.

8. Aspegren DD, Wright RE, Hemler DE. Manipulation

under epidural anesthesia with corticosteroid

injection: Two case reports. J Manipulative Physiol

Ther. 1997;20(9):618-621.

9. West DT, Mathews RS, Miller MR, 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.

Proprietary


10. Foster ME, Gray RJ, Davies SJ, Macfarlane TV.

Therapeutic manipulation of the temporomandibular

joint. Br J Oral Maxillofac Surg. 2000;38(6):641-644.

11. Kohlbeck FJ, Haldeman S. Technical assessment:

Medication assisted spinal manipulation. Spine J.

2002;2(4).

12. 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.

13. Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S.

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):245-252.

14. Maxwell HA, Turner PG. Dislocation of the Austin

Moore hemiarthroplasty: Is closed manipulation

justified? J R Coll Surg Edinb. 1994;39(6):370-371.

15. Green S, Buchbinder R, Glazier R, Forbes A.

Interventions for shoulder pain. Cochrane Database

Syst Rev. 2000;(2):CD001156.

16. Sheridan MA, Hannafin JA. Upper extremity: Emphasis

on frozen shoulder. Orthop Clin North Am. 2006;37

(4):531-539.

17. Thomas D, Williams R, Smith D. The frozen shoulder. A

review of manipulative treatment. Rheumatol Rehabil.

1980;19:173–179.

18. Hamdan TA, Al Essa KA. Manipulation under

anaesthesia for the treatment of frozen shoulder. Int

Orthop. 2003;27:107–109.

19. Speed C. Shoulder pain. In: BMJ Clinical Evidence.

London, UK: BMJ Publishing Group; February 2006.

20. Dias R, Cutts S, Massoud S. Clinical review: Frozen shoulder. Br Med J. 2005;331:1453-1456.

21. Pariente GM, Lombardi AV Jr, Berend KR, et al.

Manipulation with prolonged epidural analgesia for

treatment of TKA complicated by arthrofibrosis. Surg

Technol Int. 2006;15:221-224.

Proprietary


22. Maloney WJ. The stiff total knee arthroplasty:

Evaluation and management. J Arthroplasty. 2002;17(4

Suppl 1):71-73.

23. Kaper BP, Smith PN, Bourne RB, et al. Medium-term

results of a mobile bearing total knee replacement.

Clin Orthop Relat Res. 1999;(367):201-209.

24. Diduch DR, Scuderi GR, Scott WN, et al. The efficacy of

arthroscopy following total knee replacement.

Arthroscopy. 1997;13(2):166-171.

25. Shapiro MS, Freedman EL. Allograft reconstruction of

the anterior and posterior cruciate ligaments after

traumatic knee dislocation. Am J Sports Med. 1995;23

(5):580-587.

26. Wu LD, Xiong Y, Yan SG, Yang QS. Total knee

replacement for posttraumatic degenerative arthritis

of the knee. Chin J Traumatol. 2005;8(4):195-199.

27. Chiu KY, Ng TP, Tang WM, Yau WP. Review article: Knee

flexion after total knee arthroplasty. J Orthop Surg

(Hong Kong). 2002;10(2):194-202.

28. Esler CN, Lock K, Harper WM, Gregg PJ. Manipulation

of total knee replacements. Is the flexion gained

retained? J Bone Joint Surg Br. 1999;81(1):27-29.

29. Suresh D, Ravalia A. Analgesia for manipulation under

anaesthesia after total knee replacement. Anaesthesia.

1989;44(11):933-934.

30. Keating EM, Ritter MA, Harty LD, et al. Manipulation

after total knee arthroplasty. J Bone Joint Surg Am.

2007;89(2):282-286.

31. Foster ME, Gray RJ, Davies SJ, Macfarlane TV.

Therapeutic manipulation of the temporomandibular

joint. Br J Oral Maxillofac Surg. 2000;38(6):641-644.

32. Quraishi NA, Johnston P, Bayer J, et al. Thawing the

frozen shoulder. A randomised trial comparing

manipulation under anaesthesia with hydrodilatation.

J Bone Joint Surg Br. 2007;89(9):1197-1200.

33. Kivimäki J, Pohjolainen T, Malmivaara A, et al.

Manipulation under anesthesia with home exercises

Proprietary


versus home exercises alone in the treatment of

frozen shoulder: A randomized, controlled t rial with

125 patients. J Shoulder Elbow Surg. 2007;16(6):722

726.

34. Flannery O, Mullett H, Colville J. Adhesive shoulder

capsulitis: Does the timing of manipulation influence

outcome? Acta Orthop Belg. 2007;73(1):21-25.

35. Namba RS, Inacio M. Early and late manipulation

improve flexion after total knee arthroplasty. J

Arthroplasty. 2007;22(6 Suppl 2):58-61.

36. Magit D, Wolff A, Sutton K, Medvecky MJ. Arthrofibrosis

of the knee. J Am Acad Orthop S urg. 2007;15(11):682

694.

37. Milankov M, Miljkovic N, Stankovic M. Treatment of the

knee stiffness caused by partial patellectomy-

technical tricks. Indian J Med Sci. 2005;59(12):534-537.

38. Montgomery KD, Cavanaugh J, Cohen S, et al. Motion

complications after arthroscopic repair of anterior

cruciate ligament avulsion fractures in the adult.

Arthroscopy. 2002;18(2):171-176.

39. Noyes FR, Mangine RE, Barber SD. The early treatment

of motion complications after reconstruction of the

anterior cruciate ligament. Clin Orthop Relat Res. 1992;

(277):217-228.

40. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation

of motion following anterior cruciate ligament

reconstruction. A case-control study. Am J Sports Med.

1991;19(6):620-625.

41. Jacobs LG, Barton MA, Wallace WA, et al. Intra-articular

distension and steroids in the management of

capsulitis of the shoulder. BMJ. 1991;302(6791):1498

1501.

42. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The

resistant frozen shoulder. Manipulation versus

arthroscopic release. Clin Orthop Relat Res. 1995;

(319):238-248.

Proprietary


43. van der Heijden GJ, van der Windt DA, de Winter AF.

Physiotherapy for patients with soft tissue shoulder

disorders: A systematic review of randomised clinical

trials. BMJ. 1997;315(7099):25-30.

44. van der Windt DA, Koes BW, Deville W, et al.

Effectiveness of corticosteroid injections versus

physiotherapy for treatment of painful stiff shoulder in

primary care: Randomised trial. BMJ. 1998;317

(7168):1292-1296.

45. Buchbinder R, Green S, Youd JM, Johnston RV. Oral

steroids for adhesive capsulitis. Cochrane Database

Syst Rev. 2006;(4):CD006189.

46. American College of Occupational and Environmental

Medicine (ACOEM). Low back disorders. Occupational

medicine practice guidelines: Evaluation and

management of common health problems and

functional recovery in workers. 2nd ed. Elk Grove

Village, IL: American College of Occupational and

Environmental Medicine (ACOEM); 2007.

47. American College of Occupational and Environmental

Medicine. Chronic pain. In: Occupational medicine

practice guidelines: Evaluation and management of

common health problems and functional recovery in

workers. Elk Grove Village, IL: American College of

Occupational and Environmental Medicine (ACOEM);

2008.

48. Anderson BC. Frozen shoulder. UpToDate [online

serial]. Waltham, MA: UpToDate; May 2008.

49. National Academy of Manipulation Under Anesthesia

Physicians. Purpose Statement. San Ramon, CA:

National Academy of Manipulation Under Anesthesia

Physicians; 2002. Available

at:http://muaonline.com/pages/mua_phys_corn_national_namua.htm.

Accessed February 4, 2009.

50. Schultheis A, Reichwein F, Nebelung W. Frozen

shoulder : Diagnosis and therapy. Orthopade. 2008;37

(11):1065-1072.

Proprietary

http://muaonline.com/pages/mua_phys_corn_national_namua.htm


51. Mohammed R, Syed S, Ahmed N. Manipulation under

anaesthesia for stiffness following knee arthroplasty.

Ann R Coll Surg Engl. 2009;91(3):220-223.

52. Ng CY, Amin AK, Narborough S, et al. Manipulation

under anaesthesia and early physiotherapy facilitate

recovery of patients with frozen shoulder syndrome.

Scott Med J. 2009;54(1):29-31.

53. Kawchuk GN, Haugen R, Fritz J. A true blind for

subjects who receive spinal manipulation therapy.

Arch Phys Med Rehabil. 2009;90(2):366-368.

54. Wang JP, Huang TF, Ma HL, et al. Manipulation under

anaesthesia for frozen shoulder in patients with and

without non-insulin dependent diabetes mellitus. Int

Orthop. 2010;34(8):1227-1232.

55. Araghi A, Celli A, Adams R, Morrey B. The outcome of

examination (manipulation) under anesthesia on the

stiff elbow after surgical contracture release. J

Shoulder Elbow Surg. 2010;19(2):202-208.

56. Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat

the stiff total knee arthroplasty?: A systematic review.

Clin Orthop Relat Res. 2010;468(4):1096-1106.

57. Work Loss Data Institute. Shoulder (acute & chronic).

Encinitas, CA: Work Loss Data Institute; 2011.

58. Work Loss Data Institute. Elbow (acute & chronic).


59. Work Loss Data Institute. Forearm, wrist, & hand

(acute & chronic), not including carpal tunnel

syndrome. Encinitas, CA: Work Loss Data Institute;

2011.

60. Work Loss Data Institute. Neck and upper back (acute

& chronic). Encinitas, CA: Work Loss Data Institute;

2011.

61. Work Loss Data Institute. Low back - lumbar & thoracic

(acute & chronic). Encinitas, CA: Work Loss Data

Institute; 2011.

62. Work Loss Data Institute. Hip & pelvis (acute &

chronic). Encinitas. CA: Work Loss Data Institute; 2011.

Proprietary


63. Work Loss Data Institute. Knee & leg (acute & chronic).


64. Xiong XH, Bean A, Anthony A, et al. Manipulation for

cervical spinal dislocation under general anaesthesia:

Serial review for 4 years. Spinal Cord. 1998;36(1):21-24.

65. Kaji A, Hockberger RS. Evaluation and acute

management of cervical spinal column injuries in

adults. UpToDate [serial online]. Waltham, MA:

UpToDate; reviewed November 2013.

66. Pivec R, Issa K, Kester M, et al. Long-term outcomes of

MUA for stiffness in primary TKA. J Knee Surg. 2013;26

(6):405-410.

67. Washington State Department of Labor and Industries.

Shoulder conditions diagnosis and treatment

guideline. Olympia, WA: Washington State Department

of Labor and Industries; 2013.

68. Colorado Division of Workers' Compensation. Low

back pain medical treatment guidelines. Denver, CO:

Colorado Division of Workers' Compensation;

February 3, 2014.

69. Bidwai AS, Mayne AI, Nielsen M, Brownson P. Limited

capsular release and controlled manipulation under

anaesthesia for the treatment of frozen shoulder.

Shoulder Elbow. 2016;8(1):9-13.

70. Plate JF, Wohler AD, Brown ML, et al. Factors

associated with range of motion recovery following

manipulation under anesthesia. Surg Technol Int.

2016;XXIX:295-301.

71. 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. 2017;25(11):3637-3643.

72. Gu A, Michalak AJ, Cohen JS, et al. Efficacy of

manipulation under anesthesia for stiffness following

total knee arthroplasty: A systematic review. J

Arthroplasty. 2018;33(5):1598-1605.

Proprietary


73. Kornuijt A, Das D, Sijbesma T, et al. Manipulation

under anesthesia following total knee arthroplasty: A

comprehensive review of literature. Musculoskelet

Surg. 2018;102(3):223-230.

74. Spitler CA, Doty DH, Johnson MD, et al. Manipulation

under anesthesia as a treatment of posttraumatic

elbow stiffness. J Orthop Trauma. 2018;32(8):e304

e308.

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna 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 Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

Proprietary

AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0204 Manipulation

Under General Anesthesia

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania updated 10/16/2019

Proprietary

http://www.aetnabetterhealth.com/pennsylvania

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