Overview
This Coverage Policy addresses Manipulation under anesthesia (MUA).


Coverage Policy
A single treatment of manipulation under anesthesia* (MUA) is considered as medically necessary for
ANY of the following indications:
• adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management,
including medications with or without articular injections, home exercise programs and physical
therapy (Common Procedural Terminology [CPT] code 23700)
• post-traumatic or postoperative arthrofibrosis of the knee (e.g., total knee replacement, anterior
cruciate ligament repair) (CPT code 27570) when there is failure of conservative medical
management, including exercise and physical therapy
• reduction of a displaced fracture (e.g., vertebral, long bones) (e.g., CPT code 22505, 25675)
• reduction of acute/traumatic dislocation (e.g., vertebral, perched cervical facet) (e.g., CPT code
22505)
• chronic contracture of upper or lower extremity joint (e.g., fixed contracture from a neuromuscular
condition) when there is failure of conservative medical management including range of motion
exercise programs and physical therapy

MUA provided for these indications consists of a SINGLE treatment session. Repeat treatment
sessions involving a previously treated bone or joint are subject to medical necessity review.
Furthermore, serial treatment sessions (i.e., treatments of the same bone/joint provided
subsequently over a period of time) are not in accordance with generally accepted standards of
medical practice and are therefore not medically necessary.
MUA for any other indication, including the treatment of acute or chronic pain conditions, involving one
or more of the following joints, is considered experimental, investigational or unproven:
• ankle (CPT code 27860)
• cervical, thoracic or lumbar spine (e.g., CPT code 22505)
• elbow (CPT code 24300)
• finger (e.g., CPT code 26340, 26675)
• hip (CPT code 27275)
• pelvis, sacroiliac (CPT code 27198)
• temporomandibular (CPT code 21073)
• thumb (CPT code 26340)
• toe (CPT code 28635, 28665)
• wrist (CPT code 25259

General Background
Manipulation under anesthesia (MUA) is aimed at reducing pain and improving range of motion and is a
treatment modality that consists of manipulation and stretching procedures performed while an individual
receives anesthesia (e.g., conscious sedation, general anesthesia). A chiropractor, osteopathic physician or
medical physician may perform this type of manipulation with an anesthesiologist in attendance.
MUA is considered a safe and effective form of treatment for some joint conditions, such as arthrofibrosis of the
knee and adhesive capsulitis. It is also utilized for treatment of fractures (e.g., vertebral, long bones) and
dislocations. Although there is limited evidence in the peer-reviewed medical literature supporting safety and
efficacy for the treatment of pain conditions, MUA has been recommended as a treatment modality for acute and
chronic pain conditions, particularly of the spinal region, when standard chiropractic care and other conservative
measures have proved unsuccessful.
An individual’s protective reflex mechanism is absent under anesthesia and proponents contend it is less difficult
to separate and move the joint when the reflex is absent. During MUA, the chiropractor or physician performs a
combination of short manipulations, passive stretches and maneuvers to break up fibrous and scar tissue around
the spine and surrounding joint areas. 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). Manipulation under epidural anesthesia
(MUEA) employs an epidural, segmental anesthetic, often with simultaneous epidural steroid injections, followed
by spinal manipulation therapy. Some therapies may combine manipulation with cortisone injections into
paraspinal tissues and proliferant injections. Other forms of manipulation under anesthesia include spinal
manipulation under anesthesia (SMUA) performed with or without manipulation of other joints and total body joint
manipulation.
MUA is considered safe and effective and is a well-established method of treatment for conditions such as
adhesive capsulitis of the shoulder, arthrofibrosis of the knee, and some fractures, dislocations and contractures.
When performed for these specific conditions, MUA generally requires a single session of treatment, most often
performed unilaterally, involving a single joint. Data supporting the need for, and clinical efficacy of multiple,
repeat MUA treatment sessions for these specific conditions, is lacking in the peer-reviewed published medical
literature.

Adhesive Capsulitis/Frozen Shoulder
Adhesive capsulitis, also referred to as frozen shoulder, is used to describe a painful restriction (both passive
and active) of shoulder motion in an individual whose radiographs are typically normal. It may also be referred to
as pericapsulitis and occurs in approximately 2-5% of the general population. Some authors contend the
condition results from synovial inflammation with subsequent reactive capsular fibrosis. Early stages are treated
with steroid injections and home therapy. For refractory cases, more aggressive treatment involves manipulation
of the shoulder joint under anesthesia or an arthroscopic capsular release (Griffen, 2003). Manipulating the joint
under anesthesia breaks up the adhesions surrounding the joint and stretches the fibrotic tissue thereby
increasing joint motion and reducing pain. Evidence in the peer-reviewed published scientific literature, including
textbook sources, supports MUA may be considered for refractory cases of adhesive capsulitis of the shoulder
MUA is generally recommended for individuals who do not respond to or who
demonstrate little improvement after conservative treatment.

Postoperative/Post-traumatic Arthrofibrosis of the Knee
Arthrofibrosis of the knee is a condition that may occur following trauma, surgery or joint replacement and results
from inflammation and proliferation of scar tissue. Physiologically, traumatic injury to the knee leads to the
formation of internal scar tissue with shrinking and tightening of the joints knee capsule. Tendons outside the
joint may also shrink and tighten, leading to a further decrease of joint mobility. Treatment of arthrofibrosis of the
knee begins with physical therapy to improve motion, for refractory cases manipulation of the joint under
anesthesia may be performed. However in some cases manipulation of the joint inadvertently results in femoral
or tibial fracture, depending on the severity of adhesion formation and weak joints. As a result, some surgeons
perform an arthroscopic internal resection of scar tissue prior to manipulating the joint in order to reduce the
manipulation force and prevent fractures. MUA is indicated, with or without arthroscopy for arthrofibrosis of the
knee, when there is 2007). Published evidence in the medical literature supports MUA as a well-established safe and effective
treatment for arthrofibrosis of the knee

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 (Rotman, et al, 2019; Spitler, et al., 2018; Araghi, et al, 2012, Duke, et al.,
1991, Davilia, Johnston-Jones, 2006; Tan, et al., 2006; Chao, et al, 2002; Gaur, et al, 2003). 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 arthrofobrosis 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

Fracture and/or Dislocation
MUA is also considered a well-established and successful treatment for some types of fractures (e.g., vertebral,
long bones) and acute/traumatic dislocations (e.g., perched cervical facet). It is typically performed with surgical
Page 4 of 13
Medical Coverage Policy: 0276
repair and other medically necessary procedures such as arthroscopy. When performed in this context, MUA is
considered incidental to the base procedure.


Chronic Contracture of Upper or Lower Extremity Joint
A joint contracture is a limitation in the passive range of motion of a joint. Joint contractures prevent normal
movement of the associated body part and can result from a variety of causes such as spasticity or prolonged
immobilization. Intra-articular adhesions and peri-articular adhesions, as well as capsular, ligament and muscle
shortening and tightness may develop. As a result, activities of daily living and other skills may be adversely
affected due to the decreased mobility. In many cases, contractures can be successfully treated nonoperatively
with aggressive physical therapy or splinting with restoration of functional range of motion. When conservative
treatment fails more aggressive treatment may necessary and includes anesthetic block, maximal stretching, and
in some cases, serial casting (Garden, 2002). For joint contracture deformities, extra-articular and intra-articular
soft tissue releases are considered standard treatment (Paley, 2003). Surgical treatments include tenotomy,
tendon lengthening and joint capsule release. Manipulation under anesthesia, involving maximal passive
stretching may be considered standard treatment and is often performed in combination with serial casting
and/or surgical release when less aggressive treatments have failed.


Pain Management
Although not well-supported in the peer-reviewed published scientific literature, manipulation under anesthesia
has been proposed as a treatment for spine-related pain conditions, including but not limited to, acute or chronic
cervical pain, cervicobrachial, cervicocranial, lumbar, pelvis, or lower extremity syndromes with somatic
dysfunctions that have not responded to conservative management. Manipulation under anesthesia for pain
management often involves the spine and/or other major body joints in addition to the spine. Individuals typically
undergo a 4 to 8 week trial of conservative manipulation management (e.g., chiropractic care) prior to more
aggressive approaches, such as MUA. Authors contend failure of a trial of conservative therapy is thought to be
the primary basis for more aggressive MUA approaches (Kohlbeck, et al., 2002).
When utilized for pain management, MUA treatment typically consists of consecutive daily treatment sessions,
(generally one to five sessions, with three being the average), followed by additional outpatient chiropractic
sessions and may or may not be accompanied by steroid injections. During the procedure, manipulation of
various joints, including the spine, may be performed as part of the overall therapy plan. Cremata and associates
(2005) identified three distinct stages to MUA: sedation of the patient, specific chiropractic adjustments, and
passive stretching and traction procedures of the spine, sacroiliac and pelvis. The literature suggests maneuvers
are predetermined for each individual patient but often involves all regions of the spine (i.e., cervical, thoracic,
lumbar) as well as distal extremities and that the need for serial manipulations is determined by the degree of
biomechanical function following the initial procedure. However, there is insufficient evidence in the peerreviewed published scientific literature to support safety and efficacy of MUA for the management of acute or
chronic pain conditions, when performed as single or multiple treatment sessions.


Spine: Theoretically, spinal manipulation as a method of treatment for subluxation stretches the joint capsules
and resets the spinal cord and nerve position, allowing the nervous system to function optimally. Evidence in the
published, peer-reviewed scientific literature has failed to demonstrate the safety and efficacy of MUA when used
for the treatment of pain associated with the spine (SMUA) and some sources indicate the treatment may be
hazardous and is obsolete (Kohatsu, 2007; Lindsey, et al., 2003). In addition, anesthesia itself carries a small but
clinically significant risk. Overall, the evidence evaluating SMUA consists mainly of case reports, case series, few
controlled clinical trials and literature reviews (Peterson, et al., 2014; Taber, et al., 2013; Cremata, et al., 2005;
Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002; Kohlbeck and Haldeman, 2002; West, et al., 1999). Some of
the study results support improvement in pain and function following SMUA when compared to traditional
manipulation (Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002); however these studies are limited by lack of
randomization, small sample populations and measurement of short-term outcomes. Follow-up assessments
were generally conducted from three months to one year post-MUA treatment, some of which consisted of selfreported outcomes and questionnaires. Patient selection criteria are poorly defined and treatment protocols vary
making comparisons difficult. Much of the evidence evaluating SMUA is low quality and reliable conclusions
cannot be drawn regarding efficacy and improvement of health outcomes. Further well-designed clinical trials are
needed to support the safety and effectiveness of the procedure for the management of acute or chronic pain
conditions related to the spine.
Medical Coverage Policy: 0276


Other Joints: Evidence in the medical literature evaluating the use of MUA for management of pain conditions
involving one or more (i.e., multiple joints, whole body MUA) of other major joints such as the hip, ankle, toe,
elbow, and wrist, is lacking. Due to insufficient evidence conclusions cannot be made regarding the clinical utility
or safety and efficacy of MUA involving other single or multiple joints for pain management.
Other Conditions
There is insufficient evidence in the peer-reviewed published scientific literature to support safety and efficacy of
manipulation under anesthesia of any joint such as the hip, ankle, toe, elbow, and wrist for the treatment of any
other condition.
Professional Societies/Organizations
Published guidelines on the diagnosis and treatment of neck, upper back and low back pain prepared by the
Work Loss Data Institute (WLDI) both address MUA; MUA is listed in both documents as a procedure that was
evaluated and that is not recommended (Work Loss Data Institute, 2013a, 2013b).
According to the American College of Occupational and Environmental Medicine (ACOEM) practice guidelines
regarding physical methods of treatment for low back disorders (Hegmann, 2007; update: Hegmann, et al.,
2008), due to insufficient evidence manipulation under anesthesia (MUA) and medication-assisted spinal
manipulation (MASM) for acute, subacute or chronic low back pain is not recommended.
Centers for Medicare & Medicaid Services (CMS)
• National Coverage Determinations (NCDs): A CMS NCD Manipulation (150.1) is less broad in scope.
Please reference the CMS NCD table of contents link in the reference section.
• Local Coverage Determinations (LCDs): A CMS LCD Manipulation Under Anesthesia (MUA) (L33594) is
less broad in scope. Please reference the CMS LCD table of contents link in the reference section.
Use outside the US
No relevant information.


Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
 2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
 for reimbursement.
Coverage is limited to a SINGLE treatment session of an isolated joint condition.


SHOULDER
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)


SPINE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
22505 Manipulation of spine requiring anesthesia, any region

PELVIS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
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)


ARM
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
24300 Manipulation, elbow, under anesthesia
24605 Treatment of closed elbow dislocation; requiring anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation


WRIST
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
25259 Manipulation, wrist, under anesthesia
25690 Closed treatment of lunate dislocation, with manipulation
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint; requiring anesthesia


HAND /FINGERS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
26340 Manipulation, finger joint, under anesthesia, each joint
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989† Unlisted procedure, hands or fingers
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
†Note: Covered when medically necessary when used to report MUA of a finger or thumb
requiring anesthesia.
Medical Coverage Policy: 0276


HIP
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia
27275 Manipulation, hip joint, requiring general anesthesia


LEG
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27831 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia


KNEE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27552 Closed treatment of knee dislocation; requiring anesthesia
27562 Closed treatment of patellar dislocation; requiring anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)


ANKLE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28545 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia


FOOT/TOES
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
Experimental, investigational or unproven when used to report manipulation under anesthesia of a
single joint or multiple body joints for any other condition, including the management of acute or chronic
pain conditions:
Medical Coverage Policy: 0276


CPT®* Codes Description
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia
service (ie, general or monitored anesthesia care)
22505 Manipulation of spine requiring anesthesia, any region
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)
24300 Manipulation, elbow, under anesthesia
25259 Manipulation, wrist, under anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation
25690 Closed treatment of lunate dislocation, with manipulation
26340 Manipulation, finger joint, under anesthesia, each joint
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint, requiring anesthesia
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989 Unlisted procedure, hands or fingers
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
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
*Current Procedural Terminology (CPT®) ©2017 American Medical Association: Chicago, IL




References:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0276_coveragepositioncriteria_spinal_manipulation_under_anesthesia.pdf