Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-MED-65 Manipulation Under Anesthesia Form

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the use of manipulation under anesthesia of the spine. This document also addresses the use of manipulation under anesthesia of joints other than the knee and shoulder. Anesthesia types may include local, regional, intravenous (IV) monitored sedation, and general.

Note: Please see the following related documents for additional information:

  • CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
  • CG-SURG-09 Temporomandibular Disorders
  • CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures

Clinical Indications

Medically Necessary:

Manipulation under anesthesia of the spine is considered medically necessary for the treatment of vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine.

Not Medically Necessary:

Manipulation under anesthesia of the spine is considered not medically necessary for all other diagnoses not listed above.

Manipulation under anesthesia of any other joint not listed above as medically necessary, except for the knee or shoulder, is considered not medically necessary.