Manipulation Under Anesthesia

Policy ID: S-197-014

Section: Surgery

Effective Date: September 01, 2019

Revised Date: May 11, 2022

Revision Effective Date: May 05, 2025

Last Reviewed: March 11, 2025

Applies To: Commercial and Medicaid Expansion

Description

Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the individual receives anesthesia (usually general anesthesia or moderate sedation).

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

MUA of the Knee

MUA of the knee may be considered medically necessary when ALL of the following are met:

To treat significant arthrofibrosis of the knee resulting from trauma or knee surgery; and
After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
Is limited to a single treatment session.

MUA of the knee is considered not medically necessary for the following indication:

Serial manipulations of the same joint (MUA is limited to a single treatment session).

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the knee not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

27570

MUA of the Shoulder

MUA of the shoulder may be considered medically necessary when ALL of the following are met:

To treat capsulitis of the shoulder; and
After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
Is limited to a single treatment session.

MUA of the shoulder is considered not medically necessary for the following indication:

For serial manipulations of the same joint (MUA is limited to a single treatment session).

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the shoulder not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

23700

MUA of the Ankle, Elbow, Finger, Hip, Pelvic Ring, Spine, and Wrist

MUA of the ankle, elbow, finger, hip, pelvic ring, spine, and wrist is considered not medically necessary.

Procedure Codes

22505

24300

25259

26340

27198

27275

27860

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; and
Length of time that the individual has been symptomatic.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 27570

M24.661

M24.662

Z96.651

Z96.652

Z96.653

Covered Diagnosis Codes for Procedure Code 23700

M75.01

M75.02

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New Policy

Internal Medical Policy Committee 5-19-2020 Annual Review,

Changed Title
Updated language

Internal Medical Policy Committee 5-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 9-21-2021 Coding update

Added procedure code 27194, and
Removed diagnosis codes Z96.659 and M75.00

Internal Medical Policy Committee 5-24-2022 Revision with Coding

Removed procedure code 27194
Removed diagnosis code M24.699

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 3-11-2025 Annual Review - no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-197-013

Section: Surgery

Effective Date: September 01, 2019

Revised Date: May 11, 2022

Revision Effective Date: July 04, 2022

Last Reviewed: May 23, 2023

Archived Date: May 04, 2025

Applies To: Commercial and Medicaid Expansion

Description

Criteria

MUA of the Knee

MUA of the knee may be considered medically necessary when ALL of the following are met:

To treat significant arthrofibrosis of the knee resulting from trauma or knee surgery; and
After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
Is limited to a single treatment session.

MUA of the knee is considered not medically necessary for the following indication:

Serial manipulations of the same joint (MUA is limited to a single treatment session).

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the knee not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

27570

MUA of the Shoulder

MUA of the shoulder may be considered medically necessary when ALL of the following are met:

To treat capsulitis of the shoulder; and
After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
Is limited to a single treatment session.

MUA of the shoulder is considered not medically necessary for the following indication:

For serial manipulations of the same joint (MUA is limited to a single treatment session).

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the shoulder not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

23700

MUA of the Ankle, Elbow, Finger, Hip, Pelvic Ring, Spine, and Wrist

MUA of the ankle, elbow, finger, hip, pelvic ring, spine, and wrist is considered not medically necessary.

Procedure Codes

22505

24300

25259

26340

27198

27275

27860

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; and
Length of time that the individual has been symptomatic.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 27570

M24.661

M24.662

Z96.651

Z96.652

Z96.653

Covered Diagnosis Codes for Procedure Code 23700

M75.01

M75.02

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New Policy

Internal Medical Policy Committee 5-19-2020 Annual Review,

Changed Title
Updated language

Internal Medical Policy Committee 5-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 9-21-2021 Coding update

Added procedure code 27194, and
Removed diagnosis codes Z96.659 and M75.00

Internal Medical Policy Committee 5-24-2022 Revision with Coding

Removed procedure code 27194
Removed diagnosis code M24.699

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Manipulation Under Anesthesia

Description

Policy Application

Criteria

Procedure Code

Procedure Code

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 27570

Covered Diagnosis Codes for Procedure Code 23700

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer