Manipulation Under General Anesthesia - Medical Clinical Policy Bulletins | Aetna Page 1 of 34
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Manipulation Under General Anesthesia
Policy History
Last Review
10/16/2019
Effective: 03/12/1998
Next
Review: 02/13/2020
Review History
Definitions
Additional Information
Clinical Policy Bulletin
Notes
Number: 0204
Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
I. Aetna considers spinal manipulation under general
anesthesia (MUA) experimental and investigational.
This procedure has not been established as either safe
or effective for the treatment of musculoskeletal
disorders such as neck and back problems. Critical
issues such as selection criteria, outcome assessments,
and long-term benefits need to be addressed by well-
designed studies before this procedure can be
considered as an essential part of conservative therapy.
In this regard, the Guidelines for Chiropractic Quality
Assurance and Practice Parameters published from the
proceedings of a consensus conference commissioned
by the Congress of Chiropractic State Associations
declared that chiropractic involvement in MUA is a new
area of special interest that needs further investigation.
II. Aetna considers MUA medically necessary for the
following indications:
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A. Arthrofibrosis of knee following total knee arthroplasty,
knee surgery, or fracture (see Appendix); or
B. Chronic, refractory frozen shoulder (adhesive capsulitis)
(see Appendix); or
C. Temporomandibular joint disorders.
III. Aetna considers MUA for injuries of the cruciate
ligaments, of multiple joints, for disorders of other body
joints (e.g., ankle, elbow, finger, hip, pelvis, toe, and
wrist), or for osteoporotic thoracolumbar vertebral
compression fracture experimental and investigational
because there is insufficient evidence to support this
approach.
IV. Aetna considers MUA of the hand/fingers after
collagenase clostridium histolyticum (Xiaflex) injections
for the treatment of Dupuytren's contracture
experimental and investigational.
Note: This policy is not intended to apply to examinations
under anesthesia, or to setting fractures or complete joint
dislocations under anesthesia.
Background
Manipulation under anesthesia (MUA) is a noninvasive
treatment technique used to treat acute and chronic
conditions, including muscular or spinal pain. Under
anesthesia, spastic muscles are believed to relax and pain
sensations diminish, which theoretically may permit joint
manipulation through a full range of motion.
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During manipulation under anesthesia, in addition to the
manipulation, passive stretches and specific articular and
postural kinesthetic maneuvers may be performed in order to
break up fibrous adhesions and scar tissue around the spine
and surrounding tissues.
Spinal manipulation under anesthesia (SMUA) has been used
mostly by osteopaths and to a much lesser degree by
orthopedists to treat spinal dysfunction. This procedure was
typically performed in 1 single session. More recently, some
chiropractors, with the assistance of anesthesiologists, have
also employed this technique to alleviate acute and chronic
neck and back pain.
The rationale for this approach is that fibrotic changes in the
peri-articular and intra-articular soft tissues hinder movement,
and sometimes it is necessary to anesthetize patients to
reduce muscle tone and protective reflex mechanisms so that
the spine can be manipulated effectively. This maneuver
supposedly will break up adhesions within the surrounding
spinal joints and stretch the restricting fibrotic tissue to a length
compatible with motion, thereby, increasing joint function and
reducing pain.
Within the realm of chiropractic, SMUA is generally performed
daily for 1 to 5 consecutive days on an outpatient basis, and is
followed by a post-SMUA rehabilitation regimen, which
entails 1 week of daily manipulation to maintain joint mobility
and avoid re-adhesion of fibrotic tissue. Anesthesia is usually
induced by intravenous Pentothal (sodium thiopental), and
manipulation of the affected joints takes about 7 to 10 minutes.
Although the risks associated with spinal manipulation and
SMUA appear remote, serious complications following lumbar
spinal manipulation, including massive cauda equina
compression and vertebral pedicle fracture have been
reported. For manipulation of the cervical spine, there is an
increased chance of basivertebral and/or vertebral artery
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injury. Additionally, general anesthesia carries a small but
clinically significant risk of anaphylaxis or malignant
hyperpyrexia.
An assessment on SMUA (Kohlbeck and Haldeman, 2002)
concluded that medicine assisted spinal manipulation
therapies have a relatively long history of clinical use and have
been reported in the literature for over 70 years. However,
evidence for the effectiveness of these protocols remains
largely anecdotal, based on case series mimicking many other
surgical and conservative approaches for the treatment of
chronic pain syndromes of musculoskeletal origin. There is,
however, sufficient theoretical basis and positive results from
case series to warrant further controlled trials on these
techniques.
There is a lack of reliable evidence in the peer-reviewed
published medical literature of the effectiveness of spinal
manipulation under anesthesia. Evidence of spinal
manipulation under anesthesia is of low quality, consisting
primarily of case reports and uncontrolled case series.
Limitations of current literature include small sample sizes,
lack of random assignment, and limited evidence of durability.
Other issues include uncertainties in patient selection criteria,
and differences in protocols reported in studies, making
generalizations difficult. Studies have reported on attendant
risks of spinal manipulation (see., e.g., Dan & Saccasan, 1983,
reporting on cases of serious complications after lumbar spinal
manipulation, including massive cauda equina compression
and vertebral pedicle fracture), and the risks of general
anesthesia are well known. Guidelines from the American
College of Occupational and Environmental Medicine (2007,
2008) and the Work Loss Data Institute (2011) state that spinal
manipulation under anesthesia is not recommended.
In a prospective cohort study of 68 chronic low-back pain
(LBP) patients, Kohlbeck et al (2005) measured changes in
pain and disability for LBP patients receiving treatment with
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medication-assisted manipulation (MAM) and compared these
to changes in a group only receiving spinal manipulation
therapy (SMT). Outcomes were measured using the 1998
Version 2.0 American Association of Orthopaedic
Surgeons/Council of Musculoskeletal Specialty
Societies/Council of Spine Societies Outcomes Data Collection
Instruments. The primary outcome variable was change in
pain and disability. All patients received an initial 4- to 6-week
trial of SMT, after which 42 patients received supplemental
intervention with MAM and the remaining 26 patients
continued with SMT. Low back pain and disability measures
favored the MAM group over the SMT-only group at 3 months.
This difference attenuated at 1 year. These investigators
concluded that medication-assisted manipulation appears to
offer some patients increased improvement in LBP and
disability, and stated that further investigation of these
apparent benefits in a randomized clinical trial is warranted.
Colorado Division of Workers' Compensation’s guidelines on
“Low back pain medical treatment” (2014) did not recommend
MUA.
Manipulation under anesthesia has been used for refractory
cases of frozen shoulder (adhesive capsulitis) (Dias et al,
2005). Patients with frozen shoulder may describe chronic
pain symptoms, but primarily complain of stiffness. The loss of
range of motion causes various degrees of impaired function,
including limited reaching (overhead, across the chest, etc)
and limited rotation (unable to scratch the back, put on a coat,
etc). On physical examination, patients with a frozen shoulder
will have at least a 50 % reduction in both active and passive
range of motion (ROM) compared with the unaffected shoulder
(Anderson, 2008). Range of motion is estimated as follows: (i)
the Apley scratch test is used to assess rotation of the
shoulder joint; patients with normal glenohumeral motion
should be able to scratch the midback at the T8 to T10
level; patients with frozen shoulder are not able to scratch
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even the lower back; (ii) the NFL touchdown sign is an active
maneuver used t o assess ROM of the shoulder joint and
the strength of abduction; patients with a frozen shoulder
are unable to fully lift their arm straight overhead; and ( iii)
passive movement of the arm in abduction and e xternal
rotation also is measured; the normal glenohumeral joint
rotates externally to 90 degrees and abducts to 90
degrees. Manipulation under anesthesia is not first-line
therapy for frozen shoulder because, in most cases, frozen
shoulder is a self-limited condition that responds well to
conservative therapy. In addition, MUA can actually aggravate
symptoms in some people, while others may develop a
recurrence of adhesive capsulitis. Less than 10 % of patients
will have long-term problems that require surgery or MUA
(Anderson, 2008; Ogilvie-Harris e t al, 1995).
Patients with frozen shoulder should be advised to limit
overhead positioning, overhead reaching, and lifting during the
acute period. A non-steroidal antiinflammatory drug
(NSAID) may be prescribed for pain control. Exercise is the
treatment of choice during the acute period; up to one-half of
patients with frozen shoulder may be expected to respond to
exercise therapy (van der Windt et al, 1998). Steroid injection
may hasten recovery in persons with frozen shoulder who
have concurrent rotator cuff and bicipital tendonitis (van der
Windt et al, 1998), and the addition of supervised physical
therapy following corticosteroid injection may result in more
rapid improvement than injection alone (Carette et al, 2003).
Glenohumeral intraarticular injection combined with saline
dilation is indicated for patients with greater than 50 % loss of
ROM despite a trial of physical therapy, subacromial injection,
or both (Jacobs et al, 1991).
Referral for surgery is warranted in patients who fail to have an
improvement in ROM by approximately 15 % per month with
the above measures (Anderson, 2008). There are 2 main
surgical approaches: arthroscopic dilation of the glenohumeral
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joint or MUA. The former is now more commonly performed
than the latter. Newer arthroscopic techniques carry out a
controlled capsular release rather than a forceful manipulation
with its resultant uncontrolled tearing and bleeding.
A systematic review in BMJ Clinical Evidence (Speed, 2006)
found that MUA plus intra-articular injection is "likely to be
beneficial" for persons with frozen shoulder. The conclusions
were based upon the results of 2 randomized controlled trials
(RCTs). One RCT (n = 30) found that, in people with adhesive
capsulitis, MUA plus intra-articular hydrocortisone injection
increased recovery rates compared with intra-articular
hydrocortisone injection alone at 3 months (Thomas et al,
1980). Another, weaker RCT (n = 98) found limited evidence
that more people having MUA plus intra-articular saline
injection than having manipulation alone or manipulation plus
intra-articular injection of methylprednisolone had
improvements in ROM, pain relief, and return to normal
activities (Hamdan and Al Essa, 2003). The review noted that
potential adverse effects of MUA of the shoulder include intra-
articular lesions within the glenohumeral joint (Speed, 2006).
In a Cochrane review, Green et al (2000) examined the
effectiveness of common interventions for shoulder pain.
Intervention of interest included NSAIDs, intra-articular or
subacromial glucocorticosteroid injection, oral
glucocorticosteroid treatment, physiotherapy, MUA,
hydrodilatation, or surgery. The authors concluded that there
is little evidence to support or refute the effectiveness of
common interventions for shoulder pain. They stated that
there is a need for further well-designed clinical trials to
establish a uniform method of defining shoulder disorders and
developing outcome measures which are valid, reliable and
responsive in these study populations.
Quraishi et al (2007) assessed the outcome of MUA and
hydrodilatation as treatments for adhesive capsulitis. A total of
36 patients (38 shoulders) were randomized to receive either
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method, with all patients being treated in stage II of the
disease process. The mean age of the patients was 55.2
years (44 to 70) and the mean duration of symptoms was 33.7
weeks (12 to 76). A total of 18 shoulders (17 patients)
received MUA and 20 (19 patients) received hydrodilatation.
There were 3 insulin-dependent diabetics in each group. The
mean visual analog score (VAS) in the MUA group was 5.7 (3
to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at 2
months (paired t-test p = 0.02), and 2.7 (0 to 9; n = 16) at 6
months (paired t-test, p = 0.0006). The mean score in the
hydrodilatation group was 6.1 (4 to 10; n = 20) before
treatment, 2.4 (0 to 8; n = 18) at 2 months (paired t-test, p =
0.001), and 1.7 (0 to 7; n = 18) at 6 months (paired t-test, p =
0.0006). The VAS in the hydrodilatation group were
significantly better than those in the MUA group over the
6-month follow-up period (p < 0.0001). The mean Constant
score in those manipulated was 36 (26 to 66) before
treatment, 58.5 (24 to 90) at 2 months (paired t-test, p = 0.001)
and 59.5 (23 to 85) at 6 months (paired t-test, p = 0.0006). In
the hydrodilatation group it was 28.8 (18 to 55) before
treatment, 57.4 (17 to 80) at 2 months (paired t-test, p =
0.0004) and 65.9 (28 to 92) at 6 months (paired t-test, p =
0.0005). The Constant scores in the hydrodilatation group
were significantly better than those in the MUA group over the
6-month period of follow-up (p = 0.02). The ROM improved in
all patients over the 6 months, but was not significantly
different between the groups. At the final follow-up, 94 % of
patients (17 of 18) were satisfied or very satisfied after
hydrodilatation compared with 81 % (13 of 16) of those who
received MUA. Most patients were treated successfully, but
those undergoing hydrodilatation did better than those who
underwent MUA.
Kivimäki and colleagues (2007) examined the effect of MUA in
patients with frozen shoulder. A blinded randomized trial with
a 1-year follow-up was performed at 3 referral hospitals. A
total of 125 patients with clinically verified frozen shoulder
were randomly assigned to the manipulation group (n = 65) or
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control group (n = 60). Both the intervention group and the
control group were instructed in specific therapeutic exercises
by physiotherapists. Clinical data were gathered at baseline
and at 6 weeks and 3, 6, and 12 months after randomization.
The 2 groups did not differ at any time of the follow-up in terms
of shoulder pain or working ability. Small differences in
the ROM were detected favoring the manipulation group.
Perceived shoulder pain decreased during follow-up equally in
the 2 groups, and at 1 year after randomization, only slight
pain remained. Manipulation under anesthesia does not add
effectiveness to an exercise program performed by patients.
Flannery et al (2007) examined the influence of timing of MUA
for adhesive capsulitis of the shoulder on the long-term
outcome. A total of 180 consecutive patients with a diagnosis
of adhesive capsulitis according to Codman's criteria were
selected from a shoulder surgery database; 145 were
available for follow-up after a mean period of 62 months
(range of 12 to 125). All patients underwent MUA with intra-
articular steroid injection. A statistically significant
improvement in range of movement, function (Oxford Shoulder
Score) (OSS) and VAS was obtained following manipulation.
Ninety percent of the 145 patients who successfully completed
the study were satisfied with the procedure; 89 % indicated
that they would choose the same procedure again if the same
problem arose in the opposite shoulder. Eighty-three percent
of the patients had MUA performed less than 9 months from
onset of symptoms (early MUA). The remainder had MUA
performed after 9 to 40 months (late MUA). Patients who had
early intervention had a significantly better Oxford Shoulder
Score at final follow-up; mobility and pain were also letter than
in the late MUA group, but not significantly.
Manipulation under anesthesia has also been used to treat
fibroarthrosis following total knee replacement. Following total
knee arthroplasty, some patients who fail to achieve greater
than 90 degrees of flexion in the early peri-operative period
may be considered candidates for MUA of the knee.
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Manipulation under anesthesia is indicated in total knee
arthroplasty having less than 90 degrees ROM 4 to 12 weeks
following surgery, with no progression or regression in ROM
(Pariente et al, 2006; Magit,et al, 2007).
Keating et al (2007) assessed the outcomes of manipulation
following total knee arthroplasty. A total of 113 knees in 90
patients underwent manipulation for post-operative flexion of
greater than or equal to 90 degrees at a mean of 10 weeks
after surgery. Eighty-one (90 %) of the 90 patients achieved
improvement of ultimate knee flexion following manipulation.
The average flexion was 102 degrees prior to total knee
arthroplasty, 111 degrees following skin closure, and 70
degrees before manipulation. The average improvement in
flexion from the measurement made before manipulation to
that recorded at the 5-year follow-up was 35 degrees (p <
0.0001). The investigators reported that there was no
significant difference in the mean improvement in flexion when
patients who had manipulation within 12 weeks post-
operatively were compared with those who had manipulation
more than 12 weeks post-operatively. Patients who eventually
underwent manipulation had significantly lower pre-operative
Knee Society pain scores (more pain) than those who had not
had manipulation (p = 0.0027). The investigators concluded
that manipulation generally increases ultimate flexion following
total knee arthroplasty. They noted that patients with severe
pre-operative pain are more likely to require manipulation.
Available evidence for MUA for temporomandibular joint
syndrome is limited to small, uncontrolled studies with limited
follow-up. Foster et al (2000) conducted an uncontrolled
prospective study of manipulation of the temporomandibular
joint under anesthesia. The investigators reported that, of the
55 patients invited to participate in this study, 15 improved, 15
did not, 6 showed partial improvement, and 19 were not
treated. The median pre-treatment opening was 20 mm
(range of 13 to 27). Among those who improved after
manipulation, the median opening after treatment was 38 mm
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(range of 35 to 56). The investigators reported that some of
those who improved experienced a return of TMJ clicking but
not of joint or muscle tenderness.
There is a paucity of evidence supporting the use of MUA for
the treatment of disorders of other body joints such as the
hip, ankle, knee, and wrist.
The National Academy of Manipulation Under Anesthesia
Physicians' protocols for performing serial MUA (2002) stated
that if the patient regains 80 % or more of normal
biomechanical function during the first procedure and retains
at least 80 % of functional improvement during post MUA
evaluation, then serial MUA is usually unnecessary if post
MUA therapy and rehabilitation is performed.
Araghi et al (2010) have used a technique of elbow
examination (manipulation) under anesthesia in select patients
after surgical release to assess the smoothness of the
articulation, evaluate stability, and to stretch the flexion and
rotation arcs. The study comprised 51 consecutive patients
who underwent an examination under anesthesia between
January of 1996 and December of 2001. The examination
occurred a mean of 40 days after surgery. Forty-four patients
with a minimum of 12 months follow-up revealed a mean pre-
examination arc of 33 degrees, which improved to 73 degrees
at the final assessment. Three patients had no appreciable
change (less than 10 degrees ) in the total arc, and 1 patient
lost motion. Four patients underwent a second examination
under anesthesia at a mean of 119 days after the first
examination. The average pre-examination arc of 40 degrees
increased to 78 degrees at the final assessment (mean
improvement of 38 degrees). The only complication was
worsening of ulnar paresthesias in 3 patients; with 2 resolving
spontaneously, and 1 requiring anterior ulnar nerve
transposition. The authors concluded that examination
(manipulation) under anesthesia can be a valuable adjunctive
procedure to help regain the motion obtained at the time of
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surgical release. Moreover, they stated that because this was
not a controlled series, additional studies might be conducted
to refine those not benefiting from this procedure.
The U.S. Food and Drug Administration's labeling of Xiaflex
(collagenase Clostridium histolyticum) for Dupuytren's
contracture requires a finger extension procedure for
persistent palpable cord, which is described in the labeling as
a passive extension of a finger for 20 seconds. Local
anesthetic may be used with this procedure. The finger
extension procedure may be repeated a 2nd or 3rd time at 5-
to 10-min intervals. However, manipulation under general
anesthesia is not necessary to accomplish this procedure.
Xiong and colleagues (1998) stated that manipulation under
anesthesia (MUA) is an important method to reduce cervical
spinal dislocations in the acute stage. Causes of failure have
not been clearly identified and neurological complications can
be the major concern. All cervical dislocations have been
traditionally treated by MUA in the Christchurch Spinal Injuries
Unit as the primary treatment. These researchers reviewed all
31 patients treated from 1991 to 1995, with detailed
documentation of neurological progression and final outcome.
Three patterns were identified: bilateral dislocation, uni-facet
dislocation, and fracture dislocation. Most of the dislocations
(74 %) were successfully reduced by manipulation alone with
minimum complications. The remaining 26 % patients
required open reduction. The predominant causes of failure of
reduction by manipulation were co-existing fractures. The
success rate of reduction by manipulation was 90 % for pure bi-
facet and uni-facet dislocations, but was only 22 % for the
fracture dislocations. The authors concluded that MUA is a
safe and effective procedure for pure cervical spinal
dislocations. Fractures related to the dislocation should be
identified early and open reduction be considered.
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Also, an UpToDate review on “Evaluation and acute
management of cervical spinal column injuries in adults” (Kaji
and Hockberger, 2013) does not mention the use of MUA as a
management tool.
The Washington State Department of Labor and Industries’
guideline on “Shoulder conditions diagnosis and
treatment” (2013) recommended MUA for arthroscopic
capsular release when conventional x-rays do not show bone
pathology that can explain the loss of motion and patients
have tried and failed 12 weeks of conservative care (including
at least active assisted range of motion and home-based
exercises).
Post-Traumatic Elbow Stiffness
In a retrospective, case-series study, Spitler and colleagues
(2018) evaluated the safety and efficacy of MUA for post-
traumatic elbow stiffness. These researchers carried out a
chart review of 45 patients over a 10-year period treated with
MUA for post-traumatic elbow stiffness after elbow injuries
treated both operatively and non-operatively. Main outcome
measures were change in total flexion arc pre- to post-
manipulation; time to manipulation; and complications.
Average time from most recent surgical procedure or date of
injury to MUA was 115 days. Average pre-manipulation flexion
arc was 57.9 degrees; average flexion arc at the final follow-up
was 83.7 degrees. The improvement in elbow flexion arc of
motion was statistically significant (p < 0.001). Post-hoc
analysis of the data revealed 2 distinct groups: 28 patients
who underwent MUA within 3 months of their most recent
surgical procedure (early manipulation), and 17 patients who
underwent MUA after 3 months (late manipulation). Average
improvement in elbow flexion arc in the early MUA group was
38.3 degrees (p < 0.001); improvement in the late MUA group
was 3.1 degree. Comparison of improvement between the
early and late MUA groups found a significant difference (p <
0.001) in mean flexion arc improvement from pre-manipulation
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to post-manipulation, favoring the early group. One patient
had a complication directly attributable to MUA; 19 patients
needed additional procedures on the injured extremity after
MUA. The authors concluded that MUA was a safe and
effective adjunct to improving motion in post-traumatic elbow
stiffness when used within 3 months from the original injury or
time of surgical fixation. After 3 months, MUA did not reliably
increase elbow motion. This was a relatively small (n = 45),
retrospective study; it provided level IV evidence; these
findings need to be validated by well-designed studies.
Appendix
Condition Indications
Knee
arthrofibrosis
MUA is considered medically necessary
arthrofibrosis of knee following total knee
arthroplasty, knee surgery, or fracture in
persons having less than 90 degrees ROM
4 weeks to 6 months after surgery or
trauma.
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Frozen
shoulder
(adhesive
capsulitis)
MUA is considered medically necessary
for chronic, refractory frozen shoulder
(adhesive capsulitis) that meets the
following criteria:
I. Adhesive capsulitis should be
documented by restricted active and
passive glenohumeral and
scapulothoracic motion for at least
1-month duration which has either
reached a plateau or worsened; and
II. Significant reduction in ROM (at
least a 50 % reduction in both active
and passive ROM compared with
the unaffected shoulder); and
III. Causing various degrees of impaired
function, including limited reaching
(e.g., overhead, across the chest)
and limited rotation (e.g., unable to
scratch the back, difficulty putting
on a coat); and
IV. Persons have undergone at least 12
weeks of conservative management,
and have failed to improve,
including analgesics
or corticosteroids, physical therapy
or therapeutic exercises, and
subacromial corticosteroid injection
or hydrodilatation (arthrographic
distension, hydrodilation,
hydroplasty); and
V. Conventional x-rays do not show
bone pathology that can explain the
loss of motion.
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CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
MUA of spine:
CPT codes not covered for indications listed in the CPB (not all-inclusive):
22505 Manipulation of spine requiring anesthesia, any
region
Other CPT codes related to the CPB:
00600 Anesthesia for procedures on cervical spine
and cord; not otherwise specified
00604 Anesthesia for procedures on cervical spine
and cord; procedures with patient in the sitting
position
00620 Anesthesia for procedures on thoracic spine
and cord, not otherwise specified
00625 Anesthesia for procedures on the thoracic spine
and cord, via an anterior transthoracic
approach; not utilizing 1 lung ventilation
00626 Anesthesia for procedures on the thoracic spine
and cord, via an anterior transthoracic
approach; utilizing 1 lung ventilation
00630 Anesthesia for procedures in lumbar region; not
otherwise specified
00632 Anesthesia for procedures in lumbar region;
lumbar sympathectomy
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Code Code Description
00635 Anesthesia for procedures in lumbar region;
diagnostic or therapeutic lumbar puncture
00640 Anesthesia for manipulation of the spine or for
closed procedures on the cervical, thoracic, or
lumbar spine
00670 Anesthesia for extensive spine and spinal cord
procedures (eg, spinal instrumentation or
vascular procedures)
01999 Unlisted anesthesia procedure(s)
99152 Moderate sedation services provided by the
same physician or other qualified health care
professional performing the diagnostic or
therapeutic service that the sedation supports,
requiring the presence of an independent
trained observer to assist in the monitoring of
the patient's level of consciousness and
physiological status; initial 15 minutes of
intraservice time, patient age 5 years or older
+99153 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
99156 Moderate sedation services provided by a
physician or other qualified health care
professional other than the physician or other
qualified health care professional performing
the diagnostic or therapeutic service that the
sedation supports; initial 15 minutes of
intraservice time, patient age 5 years or older
+99157 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
MUA of knee:
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Code Code Description
CPT codes covered if selection criteria are met:
27570 Manipulation of knee joint under general
anesthesia (includes application of traction or
other fixation devices)
Other CPT codes related to the CPB:
01320 Anesthesia for all procedures on nerves,
muscles, tendons, fascia, and bursae of knee
and/or popliteal area
01380 Anesthesia for all closed procedures on knee
joint
01382 Anesthesia for diagnostic arthroscopic
procedures of knee joint
01390 Anesthesia for all closed procedures on upper
ends of tibia, fibula, and/or patella
01999 Unlisted anesthesia procedure(s)
99152 Moderate sedation services provided by the
same physician or other qualified health care
professional performing the diagnostic or
therapeutic service that the sedation supports,
requiring the presence of an independent
trained observer to assist in the monitoring of
the patient's level of consciousness and
physiological status; initial 15 minutes of
intraservice time, patient age 5 years or older
+99153 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
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Code Code Description
99156 Moderate sedation services provided by a
physician or other qualified health care
professional other than the physician or other
qualified health care professional performing
the diagnostic or therapeutic service that the
sedation supports; initial 15 minutes of
intraservice time, patient age 5 years or older
+99157 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
ICD-10 codes covered if selection criteria are met :
M24.661
-
M24.669
Ankylosis of joint, knee [arthrofibrosis following
total knee arthroplasty]
S72.401+
-
S72.499+
Fracture of lower end of femur
S79.101+
-
S79.199+
Unspecified physeal fracture of lower end of
femur
S82.001+
-
S82.099+
Fracture of patella
S82.101+
-
S82.156+,
S82.191+
-
S82.199+
Fracture of upper end of tibia and other fracture
of upper end of tibia
S82.401+
-
S82.499+
Fracture of fibula
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Code Code Description
S83.200+
- S83.32+
Tear of meniscus, current injury and tear of
articular cartilage of knee, current
S89.001+
-
S89.099+
Physeal fracture of upper end of tibia
S89.201+
-
S89.299+
Physeal fracture of upper end of fibula
Z96.651 -
Z96.659
Presence of artificial knee joint [arthrofibrosis
following total knee arthroplasty]
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive) :
S86.001+
-
S86.999+
Injury of muscle, fascia and tendon at lower leg
level
S96.001+
-
S96.999+
Injury of muscle and tendon at ankle and foot
level
MUA of shoulder:
CPT codes covered if selection criteria are met:
23700 Manipulation under anesthesia, shoulder joint,
including application of fixation apparatus
(dislocation excluded)
Other CPT codes related to the CPB:
01610 Anesthesia for all procedures on nerves,
muscles, tendons, fascia, and bursae of
shoulder and axilla
01620 Anesthesia for all closed procedures on
humeral head and neck, sternoclavicular joint,
acromioclavicular joint, and shoulder joint
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Code Code Description
01622 Anesthesia for diagnostic arthroscopic
procedures of shoulder joint
01630 Anesthesia for open or surgical arthroscopic
procedures on humeral head and neck,
sternoclavicular joint, acromioclavicular joint,
and shoulder joint; not otherwise specified
01999 Unlisted anesthesia procedure(s)
99152 Moderate sedation services provided by the
same physician or other qualified health care
professional performing the diagnostic or
therapeutic service that the sedation supports,
requiring the presence of an independent
trained observer to assist in the monitoring of
the patient's level of consciousness and
physiological status; initial 15 minutes of
intraservice time, patient age 5 years or older
+99153 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
99156 Moderate sedation services provided by a
physician or other qualified health care
professional other than the physician or other
qualified health care professional performing
the diagnostic or therapeutic service that the
sedation supports; initial 15 minutes of
intraservice time, patient age 5 years or older
+99157 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
ICD-10 codes covered if selection criteria are met:
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Code Code Description
M75.00 -
M75.02
Adhesive capsulitis of shoulder [only if X-rays
do not show bone pathology that can explain
the loss of motion]
MUA of temporomandibular joint:
CPT codes covered if selection criteria are met:
21073 Manipulation of temporomandibular joint(s)
(TMJ), therapeutic, requiring an anesthesia
service (ie, general or monitored anesthesia
care)
Other CPT codes related to the CPB:
00170 Anesthesia for intraoral procedures, including
biopsy; not otherwise specified
00190 Anesthesia for procedures on facial bones or
skull; not otherwise specified
01999 Unlisted anesthesia procedure(s)
ICD-10 codes covered if selection criteria are met:
M26.601
- M26.69
Temporomandibular joint disorders
S02.400+
-
S02.413+
Fracture of malar, maxillary and zygoma bones,
unspecified and LeFort fracture
S02.600+
-
S02.69x+
Fracture of mandible
S03.00xA
-
S03.02xS
Dislocation of jaw
MUA of other joints:
CPT codes not covered for indications listed in the CPB (not all inclusive):
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Code Code Description
24300 Manipulation, elbow, under anesthesia
25259 Manipulation, wrist, under anesthesia
26340 Manipulation, finger joint, under anesthesia,
each joint
26341 Manipulation, palmar fascial cord (ie,
Dupuytren's cord), post enzyme injection (eg,
collagenase), single cord
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
27860 Manipulation of ankle under general anesthesia
(includes application of traction or other fixation
apparatus
Other CPT codes related to the CPB:
01160 Anesthesia for closed procedures involving
symphysis pubis or sacroiliac joint
01170 Anesthesia for open procedures involving
symphysis pubis or sacroiliac joint
01200 Anesthesia for procedures on bony pelvis
01202 Anesthesia for arthroscopic procedures of hip
joint
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Code Code Description
01220 Anesthesia for all closed procedures involving
upper two-thirds of femur
01250 Anesthesia for all procedures on nerves,
muscles, tendons, fascia, and bursae of upper
leg
01462 Anesthesia for all closed procedures on lower
leg, ankle, and foot
01464 Anesthesia for arthroscopic procedures of ankle
and/or foot
01470 Anesthesia for procedures on nerves, muscles,
tendons, and fascia of lower leg, ankle, and
foot; not otherwise specified
01710 Anesthesia for procedures on nerves, muscles,
tendons, fascia, and bursae of upper arm and
elbow; not otherwise specified
01730 Anesthesia for all closed procedures on
humerus and elbow
01732 Anesthesia for diagnostic arthroscopic
procedures of elbow joint
01740 Anesthesia for open or surgical arthroscopic
procedures of the elbow; not otherwise
specified
01810 Anesthesia for all procedures on nerves,
muscles, tendons, fascia, and bursae of
forearm, wrist, and hand
01820 Anesthesia for all closed procedures on radius,
ulna, wrist, or hand bones
01829 Anesthesia for diagnostic arthroscopic
procedures on the wrist
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Code Code Description
01830 Anesthesia for open or surgical
arthroscopic/endoscopic procedures on distal
radius, distal ulna, wrist, or hand joints; not
otherwise specified
01999 Unlisted anesthesia procedure(s)
99152 Moderate sedation services provided by the
same physician or other qualified health care
professional performing the diagnostic or
therapeutic service that the sedation supports,
requiring the presence of an independent
trained observer to assist in the monitoring of
the patient's level of consciousness and
physiological status; initial 15 minutes of
intraservice time, patient age 5 years or older
+99153 each additional 15 minutes intraservice time
(List separately in addition to code for primary
service)
Other HCPCS codes related to the CPB:
J0775 Injection, collagenase, clostridium histolyticum,
0.01 mg
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
M00.011
M24.659,
M24.671
M26.59,
M26.70
M72.9,
M75.100
M99.9
Diseases of the musculoskeletal system and
connective tissue [other than those listed as
covered]
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The above policy is based on the following references:
1. Guidelines for Chiropractic Quality Assurance and
Practice Parameters: Proceedings of the Mercy Center
Consensus Conference, Burlingame, CA, January 25 -
30, 1992. S Haldeman, et al., eds. Gaithersburg, MD:
Aspen Publishers, Inc.; 1993.
2. Dreyfuss P, Michaelsen M, Horne M. MUJA:
Manipulation under joint anesthesia/analgesia: A
treatment approach for recalcitrant low back pain of
synovial joint origin. J Manipulative Physiol Ther.
1995;18(8):537-546.
3. Davis CG. Chronic cervical spine pain treated with
manipulation under anesthesia. J
Neuromusculoskeletal Syst. 1996;4:102-115.
4. Ben-David B, Raboy M. Manipulation under anesthesia
combined with epidural steroid injection. J
Manipulative Physiol Ther. 1994;17:605-609.
5. Alexander GK. Manipulation under anesthesia of
lumbar post-laminectomy syndrome patients with
epidural fibrosis and recurrent HNP. ACA J Chiro.
1993;June:79-81.
6. Dan NG, Saccasan PA. Serious complications of lumbar
spinal manipulation. Med J Aust. 1983;2(12):672-673.
7. Hughes BL. Management of cervical disk syndrome
utilizing manipulation under anesthesia. J Manipulative
Physiol Ther. 1993;16:174-181.
8. Aspegren DD, Wright RE, Hemler DE. Manipulation
under epidural anesthesia with corticosteroid
injection: Two case reports. J Manipulative Physiol
Ther. 1997;20(9):618-621.
9. West DT, Mathews RS, Miller MR, et al. Effective
management of spinal pain in one hundred seventy-
seven patients evaluated for manipulation under
anesthesia. J Manipulative Physiol Ther. 1999;22
(5):299-308.
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10. Foster ME, Gray RJ, Davies SJ, Macfarlane TV.
Therapeutic manipulation of the temporomandibular
joint. Br J Oral Maxillofac Surg. 2000;38(6):641-644.
11. Kohlbeck FJ, Haldeman S. Technical assessment:
Medication assisted spinal manipulation. Spine J.
2002;2(4).
12. Palmieri NF, Smoyak S. Chronic low back pain: A study
of the effects of manipulation under anesthesia. J
Manipulative Physiol Ther. 2002;25(8):E8-E17.
13. Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S.
Supplemental care with medication-assisted
manipulation versus spinal manipulation therapy
alone for patients with chronic low back pain. J
Manipulative Physiol Ther. 2005;28(4):245-252.
14. Maxwell HA, Turner PG. Dislocation of the Austin
Moore hemiarthroplasty: Is closed manipulation
justified? J R Coll Surg Edinb. 1994;39(6):370-371.
15. Green S, Buchbinder R, Glazier R, Forbes A.
Interventions for shoulder pain. Cochrane Database
Syst Rev. 2000;(2):CD001156.
16. Sheridan MA, Hannafin JA. Upper extremity: Emphasis
on frozen shoulder. Orthop Clin North Am. 2006;37
(4):531-539.
17. Thomas D, Williams R, Smith D. The frozen shoulder. A
review of manipulative treatment. Rheumatol Rehabil.
1980;19:173–179.
18. Hamdan TA, Al Essa KA. Manipulation under
anaesthesia for the treatment of frozen shoulder. Int
Orthop. 2003;27:107–109.
19. Speed C. Shoulder pain. In: BMJ Clinical Evidence.
London, UK: BMJ Publishing Group; February 2006.
20. Dias R, Cutts S, Massoud S. Clinical review: Frozen shoulder. Br Med J. 2005;331:1453-1456.
21. Pariente GM, Lombardi AV Jr, Berend KR, et al.
Manipulation with prolonged epidural analgesia for
treatment of TKA complicated by arthrofibrosis. Surg
Technol Int. 2006;15:221-224.
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Manipulation Under General Anesthesia - Medical Clinical Policy Bulletins | Aetna Page 28 of 34
22. Maloney WJ. The stiff total knee arthroplasty:
Evaluation and management. J Arthroplasty. 2002;17(4
Suppl 1):71-73.
23. Kaper BP, Smith PN, Bourne RB, et al. Medium-term
results of a mobile bearing total knee replacement.
Clin Orthop Relat Res. 1999;(367):201-209.
24. Diduch DR, Scuderi GR, Scott WN, et al. The efficacy of
arthroscopy following total knee replacement.
Arthroscopy. 1997;13(2):166-171.
25. Shapiro MS, Freedman EL. Allograft reconstruction of
the anterior and posterior cruciate ligaments after
traumatic knee dislocation. Am J Sports Med. 1995;23
(5):580-587.
26. Wu LD, Xiong Y, Yan SG, Yang QS. Total knee
replacement for posttraumatic degenerative arthritis
of the knee. Chin J Traumatol. 2005;8(4):195-199.
27. Chiu KY, Ng TP, Tang WM, Yau WP. Review article: Knee
flexion after total knee arthroplasty. J Orthop Surg
(Hong Kong). 2002;10(2):194-202.
28. Esler CN, Lock K, Harper WM, Gregg PJ. Manipulation
of total knee replacements. Is the flexion gained
retained? J Bone Joint Surg Br. 1999;81(1):27-29.
29. Suresh D, Ravalia A. Analgesia for manipulation under
anaesthesia after total knee replacement. Anaesthesia.
1989;44(11):933-934.
30. Keating EM, Ritter MA, Harty LD, et al. Manipulation
after total knee arthroplasty. J Bone Joint Surg Am.
2007;89(2):282-286.
31. Foster ME, Gray RJ, Davies SJ, Macfarlane TV.
Therapeutic manipulation of the temporomandibular
joint. Br J Oral Maxillofac Surg. 2000;38(6):641-644.
32. Quraishi NA, Johnston P, Bayer J, et al. Thawing the
frozen shoulder. A randomised trial comparing
manipulation under anaesthesia with hydrodilatation.
J Bone Joint Surg Br. 2007;89(9):1197-1200.
33. Kivimäki J, Pohjolainen T, Malmivaara A, et al.
Manipulation under anesthesia with home exercises
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versus home exercises alone in the treatment of
frozen shoulder: A randomized, controlled t rial with
125 patients. J Shoulder Elbow Surg. 2007;16(6):722
726.
34. Flannery O, Mullett H, Colville J. Adhesive shoulder
capsulitis: Does the timing of manipulation influence
outcome? Acta Orthop Belg. 2007;73(1):21-25.
35. Namba RS, Inacio M. Early and late manipulation
improve flexion after total knee arthroplasty. J
Arthroplasty. 2007;22(6 Suppl 2):58-61.
36. Magit D, Wolff A, Sutton K, Medvecky MJ. Arthrofibrosis
of the knee. J Am Acad Orthop S urg. 2007;15(11):682
694.
37. Milankov M, Miljkovic N, Stankovic M. Treatment of the
knee stiffness caused by partial patellectomy-
technical tricks. Indian J Med Sci. 2005;59(12):534-537.
38. Montgomery KD, Cavanaugh J, Cohen S, et al. Motion
complications after arthroscopic repair of anterior
cruciate ligament avulsion fractures in the adult.
Arthroscopy. 2002;18(2):171-176.
39. Noyes FR, Mangine RE, Barber SD. The early treatment
of motion complications after reconstruction of the
anterior cruciate ligament. Clin Orthop Relat Res. 1992;
(277):217-228.
40. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation
of motion following anterior cruciate ligament
reconstruction. A case-control study. Am J Sports Med.
1991;19(6):620-625.
41. Jacobs LG, Barton MA, Wallace WA, et al. Intra-articular
distension and steroids in the management of
capsulitis of the shoulder. BMJ. 1991;302(6791):1498
1501.
42. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The
resistant frozen shoulder. Manipulation versus
arthroscopic release. Clin Orthop Relat Res. 1995;
(319):238-248.
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43. van der Heijden GJ, van der Windt DA, de Winter AF.
Physiotherapy for patients with soft tissue shoulder
disorders: A systematic review of randomised clinical
trials. BMJ. 1997;315(7099):25-30.
44. van der Windt DA, Koes BW, Deville W, et al.
Effectiveness of corticosteroid injections versus
physiotherapy for treatment of painful stiff shoulder in
primary care: Randomised trial. BMJ. 1998;317
(7168):1292-1296.
45. Buchbinder R, Green S, Youd JM, Johnston RV. Oral
steroids for adhesive capsulitis. Cochrane Database
Syst Rev. 2006;(4):CD006189.
46. American College of Occupational and Environmental
Medicine (ACOEM). Low back disorders. Occupational
medicine practice guidelines: Evaluation and
management of common health problems and
functional recovery in workers. 2nd ed. Elk Grove
Village, IL: American College of Occupational and
Environmental Medicine (ACOEM); 2007.
47. American College of Occupational and Environmental
Medicine. Chronic pain. In: Occupational medicine
practice guidelines: Evaluation and management of
common health problems and functional recovery in
workers. Elk Grove Village, IL: American College of
Occupational and Environmental Medicine (ACOEM);
2008.
48. Anderson BC. Frozen shoulder. UpToDate [online
serial]. Waltham, MA: UpToDate; May 2008.
49. National Academy of Manipulation Under Anesthesia
Physicians. Purpose Statement. San Ramon, CA:
National Academy of Manipulation Under Anesthesia
Physicians; 2002. Available
at:http://muaonline.com/pages/mua_phys_corn_national_namua.htm.
Accessed February 4, 2009.
50. Schultheis A, Reichwein F, Nebelung W. Frozen
shoulder : Diagnosis and therapy. Orthopade. 2008;37
(11):1065-1072.
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51. Mohammed R, Syed S, Ahmed N. Manipulation under
anaesthesia for stiffness following knee arthroplasty.
Ann R Coll Surg Engl. 2009;91(3):220-223.
52. Ng CY, Amin AK, Narborough S, et al. Manipulation
under anaesthesia and early physiotherapy facilitate
recovery of patients with frozen shoulder syndrome.
Scott Med J. 2009;54(1):29-31.
53. Kawchuk GN, Haugen R, Fritz J. A true blind for
subjects who receive spinal manipulation therapy.
Arch Phys Med Rehabil. 2009;90(2):366-368.
54. Wang JP, Huang TF, Ma HL, et al. Manipulation under
anaesthesia for frozen shoulder in patients with and
without non-insulin dependent diabetes mellitus. Int
Orthop. 2010;34(8):1227-1232.
55. Araghi A, Celli A, Adams R, Morrey B. The outcome of
examination (manipulation) under anesthesia on the
stiff elbow after surgical contracture release. J
Shoulder Elbow Surg. 2010;19(2):202-208.
56. Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat
the stiff total knee arthroplasty?: A systematic review.
Clin Orthop Relat Res. 2010;468(4):1096-1106.
57. Work Loss Data Institute. Shoulder (acute & chronic).
Encinitas, CA: Work Loss Data Institute; 2011.
58. Work Loss Data Institute. Elbow (acute & chronic).
Encinitas, CA: Work Loss Data Institute; 2011.
59. Work Loss Data Institute. Forearm, wrist, & hand
(acute & chronic), not including carpal tunnel
syndrome. Encinitas, CA: Work Loss Data Institute;
2011.
60. Work Loss Data Institute. Neck and upper back (acute
& chronic). Encinitas, CA: Work Loss Data Institute;
2011.
61. Work Loss Data Institute. Low back - lumbar & thoracic
(acute & chronic). Encinitas, CA: Work Loss Data
Institute; 2011.
62. Work Loss Data Institute. Hip & pelvis (acute &
chronic). Encinitas. CA: Work Loss Data Institute; 2011.
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63. Work Loss Data Institute. Knee & leg (acute & chronic).
Encinitas, CA: Work Loss Data Institute; 2011.
64. Xiong XH, Bean A, Anthony A, et al. Manipulation for
cervical spinal dislocation under general anaesthesia:
Serial review for 4 years. Spinal Cord. 1998;36(1):21-24.
65. Kaji A, Hockberger RS. Evaluation and acute
management of cervical spinal column injuries in
adults. UpToDate [serial online]. Waltham, MA:
UpToDate; reviewed November 2013.
66. Pivec R, Issa K, Kester M, et al. Long-term outcomes of
MUA for stiffness in primary TKA. J Knee Surg. 2013;26
(6):405-410.
67. Washington State Department of Labor and Industries.
Shoulder conditions diagnosis and treatment
guideline. Olympia, WA: Washington State Department
of Labor and Industries; 2013.
68. Colorado Division of Workers' Compensation. Low
back pain medical treatment guidelines. Denver, CO:
Colorado Division of Workers' Compensation;
February 3, 2014.
69. Bidwai AS, Mayne AI, Nielsen M, Brownson P. Limited
capsular release and controlled manipulation under
anaesthesia for the treatment of frozen shoulder.
Shoulder Elbow. 2016;8(1):9-13.
70. Plate JF, Wohler AD, Brown ML, et al. Factors
associated with range of motion recovery following
manipulation under anesthesia. Surg Technol Int.
2016;XXIX:295-301.
71. Vanlommel L, Luyckx T, Vercruysse G, et al. Predictors
of outcome after manipulation under anaesthesia in
patients with a stiff total knee arthroplasty. Knee Surg
Sports Traumatol Arthrosc. 2017;25(11):3637-3643.
72. Gu A, Michalak AJ, Cohen JS, et al. Efficacy of
manipulation under anesthesia for stiffness following
total knee arthroplasty: A systematic review. J
Arthroplasty. 2018;33(5):1598-1605.
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73. Kornuijt A, Das D, Sijbesma T, et al. Manipulation
under anesthesia following total knee arthroplasty: A
comprehensive review of literature. Musculoskelet
Surg. 2018;102(3):223-230.
74. Spitler CA, Doty DH, Johnson MD, et al. Manipulation
under anesthesia as a treatment of posttraumatic
elbow stiffness. J Orthop Trauma. 2018;32(8):e304
e308.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,
general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care
services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors
in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely
responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is
subject to change.
Copyright © 2001-2020 Aetna Inc.
Proprietary
AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0204 Manipulation
Under General Anesthesia
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania updated 10/16/2019
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