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Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually general anesthesia or moderate sedation).
Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft-tissue adhesions with less force than would be required to overcome patient resistance or apprehension. MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to reduce fractures (eg, vertebral, long bones) and dislocations.
MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spine, when standard care, including manipulation, and other conservative measures have been unsuccessful. MUA of the spine has been used in various forms since the 1930s. Complications from general anesthesia and forceful long-lever, high-amplitude nonspecific manipulation procedures led to decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival is attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.
MUA of the spine is described as follows: after sedation, a series of mobilization, stretching, and traction procedures to the spine and lower extremities are performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand, while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area when necessary to address low back pain.
MUA takes 15–20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners recommend performing the procedure on 3 or more consecutive days for best results. Care after MUA may include 4–8 weeks of active rehabilitation with manual therapy, including SMT and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal (facet) and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia) and after epidural injection of corticosteroid and local anesthetic (manipulation postepidural injection). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these may be referred to as medicine-assisted manipulation.
Manipulative procedures are not subject to regulation by the U.S. Food and Drug Administration.
POLICYSpinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.
Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered investigational.
Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain.
Note: This policy statement does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY8/2002: Approved by Medical Policy Advisory Committee (MPAC)
12/18/2003: Code Reference section updated
5/11/2009: Policy reviewed, no changes
06/22/2010: Policy was updated extensively. The title was changed from “Spinal Manipulation under Anesthesia” to “Manipulation under Anesthesia for Treatment of Chronic Spinal or Pelvic Pain.” Policy description was revised to address chronic spinal pain, chronic sacroiliac and pelvic pain. Policy statement was revised to indicate that spinal manipulation with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal pain and chronic sacroiliac and pelvic pain. The Covered Codes table was deleted, CPT code 22505 was moved to the non-covered codes table, and CPT code 00640 was added to the non-covered codes table based on this investigational policy statement. Notes were also added to indicate that the policy statement does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.
12/30/2010: Deleted "for Treatment of Chronic Spinal or Pelvic Pain” from the policy title. Added two investigational policy statements: 1) Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered investigational. 2)Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain.
12/01/2011: Policy reviewed; no changes.
12/13/2012: Policy reviewed; no changes.
03/12/2014: Policy reviewed; no changes.
01/21/2015: Policy description updated regarding MUA treatment for isolated joint conditions, acute and chronic pain conditions, and spinal manipulation. Policy statements unchanged.
07/31/2015: Code Reference section updated for ICD-10.
05/26/2016: Policy number A.8.01.40 added. Investigative definition updated in Policy Guidelines.
09/23/2016: Policy reviewed; no changes.
Blue Cross Blue Shield Association policy # 8.01.40
CODE REFERENCENote: The policy statement does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.
This may not be a comprehensive list of procedure codes applicable to this policy.