Medical Coverage Policy: 0276

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based.

For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies.

In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service;
2. any applicable laws/regulations;
3. any relevant collateral source materials including Coverage Policies and;
4. the specific facts of the particular situation.

Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment where appropriate and have discretion in making individual coverage determinations.

Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).

Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy (see “Coding Information” below). When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.

Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

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/standard chiropractic treatment (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/standard chiropractic treatment
• 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/standard chiropractic treatment

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)
• elbow (CPT code 24300)
• hip (CPT code 27275)
• pelvis, sacroiliac (CPT code 27198)
• temporomandibular (CPT code 21073)
• thumb (CPT code 26340)
• toe (CPT code 28635, 28665)
• cervical, thoracic or lumbar spine (e.g., CPT code 22505)
• finger (e.g., CPT code 26340, 26675)
• wrist (CPT code 25259)

General Background

Manipulation under anesthesia (MUA), a treatment modality aimed at reducing pain and improving range of motion, 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. 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 known as frozen shoulder or pericapsulitis), is a painful restriction (both passive and active) of shoulder motion in an individual whose radiographs are typically normal. It 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 the consideration of MUA for refractory cases of adhesive capsulitis of the shoulder (Miller, et al., 2021; Srikesavan, et al., 2021; Kim, et al., 2020; Brealey, et al., 2020; Alsubheen, et al., 2019; Rolle, 2017; Vastamaki, 2013; Maund, et al., 2012; Kivimaki, et al., 2007; Wang, et al., 2007; Sheridan and Hannafin, 2006; Dias, et al., 2005; Farrell, et al., 2005; Hamdan and Essa, 2003; Nirschl and Willet, 2002). 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 caused by inflammation and proliferation of scar tissue following trauma, surgery or joint replacement. Traumatic injury to the knee can cause the formation of internal scar tissue with shrinking and tightening of the joint capsule. Tendons outside the joint may also shrink and tighten, leading to 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. In some cases, depending on the severity of adhesion formation and joint weakness, manipulation of the joint may inadvertently result in femoral or tibial fracture. As a precaution, some surgeons perform an arthroscopic internal resection of scar tissue prior to manipulation in order to reduce force and prevent fractures.

MUA is indicated, with or without arthroscopy for arthrofibrosis of the knee, when there is < 90° range of motion following surgery or trauma despite physical therapy (Magit, et al. 2007). Published evidence in the medical literature supports MUA as a well-established safe and effective treatment for arthrofibrosis of the knee (Haffar, et al., 2022; Randsborg, et al., 2020; Gu, et al., 2018 ; Issa, et al., 2014a; Issa, et al., 2014b; Pivec, et al., 2013; Ghani, et al., 2012; Ipach, et al., 2011; Fitzsimmons, et al., 2010; Mohammed, et al., 2009; Keating, et al., 2007; Magit, et al., 2007; Namba and Inacio, 2007; D'Amato and Bach, 2003; Esler, et al. 1999).

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 splinting (Araghi, et al, 2010). MUA may be recommended when there is failure to 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 MUA 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 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.

Fracture and/or Dislocation

MUA is 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 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 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. More aggressive treatment 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, MUA 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 used for pain management, MUA treatment typically consists of one to five consecutive daily sessions (with an average of three), followed by additional outpatient chiropractic sessions which may be accompanied by steroid injections. During treatment, 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. While the literature suggests maneuvers are predetermined for each individual patient, all regions of the spine (i.e., cervical, thoracic, lumbar) and distal extremities are typically involved. The need for serial manipulations is determined by the degree of biomechanical function following the initial procedure.

However, there is insufficient evidence in the peer-reviewed 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 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 self-reported outcomes and questionnaires. Patient selection criteria are poorly defined and treatment protocols vary making comparisons difficult.

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, safety, or 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

The American College of Occupational and Environmental Medicine (ACOEM) published practice guidelines regarding physical methods of treatment for low back disorders (Hegmann, 2007; Hegmann, et al., 2008; Hegmann, et al., 2020). The authors determined that manipulation under anesthesia (MUA) and medication-assisted spinal manipulation (MASM) are not recommended for acute, subacute, or chronic low back pain due to a lack of evidence.

The International Chiropractors Association issued at policy statement on Manipulation Under Anesthesia in 2017. The group stated, "within the armamentarium of chiropractic techniques efficient methods exist that address the pain profiles of even the most sensitive patient. Furthermore, the chiropractic adjustment relies on the body's own inherent constructive survival mechanisms to innately accomplish adjustic correction." They concluded that anesthesia is inappropriate and unnecessary to the delivery of chiropractic adjustment.

Use outside the US

No relevant information.