Latest Review Date: May 2024

Category:  Surgery       

POLICY:

Joint manipulation under anesthesia may be considered medically necessary for the following indications:

• Treatment of frozen shoulder (adhesive capsulitis); when there is failure of conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy.
• Treatment of arthrofibrosis of knee following total knee arthroplasty, knee surgery, or fracture in persons having less than 90 degree range of motion, six or more weeks status post-surgery or traumatic event.
• Treatment of complete joint dislocations or to set fractures.
• Treatment status-post surgery or in conjunction with pin placement will be reviewed individually for other joints, i.e., fingers or toes.

MUA provided for the above indications usually consist of a single treatment session involving an isolated joint.  Repeat treatment sessions or multiple joint manipulations under anesthesia are subject to medical necessity review.

Manipulation of joints under anesthesia involving serial treatment sessions is considered not medically necessary.

Joint manipulation under anesthesia is considered not medically necessary for the treatment of other disorders of joints (e.g., pelvis, hip, ankle, elbow, wrist, toe, temporomandibular joint, and finger) or for the treatment of acute or chronic pain conditions.

Manipulation of multiple joints under anesthesia is considered not medically necessary.

DESCRIPTION OF PROCEDURE OR SERVICE:

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., long bones) and dislocations.

Because the patient’s protective reflex mechanism is absent under anesthesia, proponents contend it is less difficult to separate and move the joint. The physician performs a combination of short manipulations, passive stretches and maneuvers to break up fibrous and scar tissue around the joint area. This manipulation typically includes a high velocity thrust (i.e., a technique that adjusts the joints rapidly), which may be followed by a popping or snapping sound.

In a less frequently used technique, manipulation under anesthesia (MUA) may be accompanied by fluoroscopically-guided intra-articular injections with corticosteroid agents to reduce inflammation. This procedure is referred to as manipulation under joint anesthesia/analgesia (MUJA).

For manipulation of spine under anesthesia refer to Medical Policy #154- Manipulation under Anesthesia for Treatment of Chronic Spinal or Pelvic Pain.

KEY POINTS:

Summary of Evidence

MUA for Treatment of Adhesive Capsulitis of the Shoulder

For individuals who have adhesive capsulitis of the shoulder who receive manipulation under anesthesia, the evidence is sufficient to determine the effects of the technology on health outcomes.

MUA for Postoperative/Post-traumatic Arthrofibrosis of the Knee

Published evidence in the medical literature supports MUA as a well-established safe and effective treatment for arthrofibrosis of the knee. The evidence is sufficient to determine the effects of the technology on health outcomes.

Postoperative/Post-traumatic Arthrofibrosis of the Elbow

Arthrofibrosis of the elbow often occurs following injury (e.g., operative, fracture). The elbow becomes stiff as a result of soft-tissue contracture of the ligaments, muscles and/or tendons. Early management generally involves bracing and splints (Araghi, et al, 2010). Manipulation under anesthesia may be recommended when there is failure to progress improve and progress following the use of bracing. Operative release may be considered a treatment option depending on the cause of the contracture, the presence of pain or other symptoms, and decrease in functional level.

Published evidence in the peer reviewed scientific literature supporting the safety and effectiveness of using manipulation under anesthesia of the elbow is limited to retrospective case series, involve small sample populations and lack control groups. Few studies lend support to clinical effectiveness for the treatment of joint stiffness/fibrosis when other conservative measures, such as bracing and splinting, have failed to improve range of motion. In addition, evidence-based clinical practice guidelines supporting MUA for arthrofibrosis of the elbow are not available. There is insufficient evidence in the peer-reviewed published literature and lack of consensus among professional societies to support the effectiveness of MUA as treatment for arthrofibrosis of the elbow.

Evidence supporting the use of MUA for management of pain conditions involving other major joints, multiple body joints or whole body MUA, such as the hip, ankle, elbow, and wrist was not found in the medical literature. Due to insufficient evidence, conclusions cannot be made regarding the clinical utility or safety and efficacy of MUA involving other joints or multiple joints for pain management. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking and is insufficient to determine whether MUA improves health outcomes; thus, it is considered investigational.

Practice Guidelines and Position Statements

American Academy of Osteopathy (AAO)

The American Academy of Osteopathy (AAO) published a consensus statement in 2005 on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. The AAO states that manipulation under anesthesia may be appropriate in cases of restrictions and abnormalities of function that include recurrent muscle spasm, range-of-motion restrictions, persistent pain secondary to injury and/or repetitive motion trauma, and is in general 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 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.

U.S. Preventive Services Task Force Recommendations

The U.S. Preventive Services Task Force has not addressed manipulation under anesthesia.

KEY WORDS:

Manipulation under anesthesia, MUA, manipulation under joint anesthesia/analgesia, MUJA

APPROVED BY GOVERNING BODIES:

Manipulative procedures are not subject to regulation by the U.S. Food and Drug Administration (FDA).

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.   

CURRENT CODING:

CPT Codes:    

REFERENCES:

1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo. www.orthoinfo.aaos.org/en/diseases-- conditions/frozen-shoulder/.
2. 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.
3. Araghi A, Celli A, Adams R, Morrey B. The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release. Shoulder Elbow Surg. 2010 Mar; 19(2):202-208.
4. 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.
5. Brealey S, Northgraves M, Kottam L, et al. Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: The UK FROST three-arm RCT. Health Technol Assess. 2020;24(71):1-162.
6. 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
7. Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review. Clin Orthop Relat Res. 2010 Apr; 468(4):1096-1106.
8. Ghani H, Maffulli N, Khanduja V. Management of stiffness following total knee arthroplasty: A systematic review. Knee. 2012 Apr 23.
9. Gu A, Michalak AJ, Cohen JS. Efficacy of Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review. J Arthroplasty. 2018 May;33(5):1598-1605.
10. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
11. Ipach I, Mittag F, Lahrmann J, Kunze B, Kluba T. Arthrofibrosis after TKA - Influence factors on the absolute flexion and gain in flexion after manipulation under anaesthesia. BMC Musculoskelet Disord. 2011 Aug 12; 12:184.
12. Issa K, Banerjee S, Kester MA, Khanuja HS, Delanois RE, Mont MA. The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty. J Bone Joint Surg Am. 2014 Aug 20; 96(16):1349-57.
13. Issa K, Kapadia BH, Kester M, Khanuja HS, Delanois RE, Mont MA. Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty. J Arthroplasty. 2014 Mar; 29(3):548-52.
14. 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.
15. 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.
16. Lee S-J, Jang J-H, Hyun Y-S, et al. Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: The necessity of arthroscopic capsular release in primary FS. Clin Shoulder Elb. 2020;23(4):169-177.
17. Magit D, Wolff A, Sutton K and Medvecky MJ. Arthrofibrosis of the knee. J Am Acad Orthop Surg 2007; 15 (11):682-694.
18. Mun S, Baek C. Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study. J Shoulder Elbow Surg. 2016 Dec;25(12):1937-1943.
19. 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.
20. 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. 2020;140: 785–791.
21. Yeoh D, Nicolaou N, Goddard R, Manipulation under anesthesia post total knee replacement: long term follow up. Knee. 2012; 19(4): 329-331.

POLICY HISTORY:

Medical Policy Group, January 2009 (3)

Medical Policy Administration Committee, February 2009

Available for comment February 6-March 23, 2009

Medical Policy Group, February 2009 (2)

Medical Policy Administration Committee, March 2009

Medical Policy Group, March 2009 (3)

Medical Policy Administration Committee, April 2009

Available for comment April 3-May 18, 2009

Medical Policy Group; June 2011: Policy addition to cover ‘serial treatment sessions’ and ‘multiple joints’, Key Points Update

Medical Policy Administration Committee; July 2011

Available for comment July 6 through August 22, 2011

Medical Policy Group, October 2012 (1): 2012 Updates – No new literature identified, policy remains unchanged.

Medical Policy Panel, December 2013

Medical Policy Group, January 2014 (2): Policy updated with literature search through November 2013.  Policy statement unchanged.  Key Points and References updated. 

Medical Policy Panel, December 2014

Medical Policy Group, December 2014 (4): Updates to Description and Key Points. Policy statement updated to include Manipulation of joints “under anesthesia” involving serial treatment sessions is considered not medically necessary. Added code 23700.

Medical Policy Group, August 2016 (7): No new literature to add; policy statements remain unchanged by consensus.  

Medical Policy Group, December 2016: 2017 Annual Coding Update.  Created Previous Coding section and moved CPT code 27194 to this section; added 27198 to Current Coding.

Medical Policy Group, September 2017 (7): Independent literature review completed; updates to Key Points and References. No change to Policy Statement based on literature review and consensus.  

Medical Policy Group, June 2021 (7): Independent literature review completed. Updated Key Points and References. Deleted Previous Coding section. No changes to Policy Statement.

Medical Policy Group, May 2022 (7): Independent literature review completed. Updated Key Points and References. No changes to Policy Statement.

Medical Policy Group, May 2023 (7): Independent literature review completed. Updated Key Points, Benefit Application, and References. No changes to Policy Statement.

Medical Policy Group, May 2024 (7): Independent literature review completed. References updated. No change to Policy Statement based on literature review and consensus.  

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.