All Policies and Precertification
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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).
MUA of the Knee
MUA of the knee may be considered medically necessary when ALL of the following are met;
MUA of the knee is considered not medically necessary for the following indications:
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
MUA of the shoulder may be considered medically necessary when ALL of the following are met:
MUA of the shoulder is considered not medically necessary for the following indications:
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.
The medical record should include the following documentation:
Covered diagnosis codes for 27570
Covered diagnosis codes for 23700
Internal Medical Policy Committee 7-16-2019 New Policy
Internal Medical Policy Committee 5-19-2020 Annual Review, Title changed
Internal Medical Policy Committee 5-20-2021 Annual Review-no changes in criteria
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.
Length of time that the individual has been symptomatic.
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