Manipulation Under Anesthesia (MUA)

Section: Surgery
Effective Date: September 01, 2019
Revised Date: July 16, 2019
Last Reviewed: May 19, 2020

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).

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 indications:

  • When above criteria have not been met; or
  • For serial manipulations.

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

  • When above criteria have not been met; or
  • For serial manipulations.

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be 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 27570

M24.661 M24.662 M24.669 Z96.651 Z96.652 Z96.653 Z96.659

 

Covered diagnosis codes for 23700

M75.00 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, Title changed

Links

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.