Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Manipulation Under Anesthesia

Policy #:11.14.24b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member’s contract.

MEDICALLY NECESSARY

Manipulation under anesthesia (MUA) is considered medically necessary and, therefore, covered for any of the following conditions:
  • Adhesive capsulitis of the shoulder (i.e., frozen shoulder) for individuals with intractable, persistent pain refractory to conservative medical management (e.g., physical therapy, home exercise programs, and NSAIDs)
  • Arthrofibrosis of the knee following trauma or knee surgery (e.g., total knee replacement, anterior cruciate ligament repair) for individuals with less than a 90-degree flexion following a formal course of physical therapy
  • Closed reduction of an acute or traumatic dislocation
  • Closed reduction of a displaced fracture

EXPERIMENTAL/INVESTIGATIONAL

Spinal manipulation under anesthesia for the treatment of chronic spinal (e.g., cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA for the treatment of adhesive capsulitis of any joint other than the shoulder such as, but not limited to, the hip, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA for the treatment of arthrofibrosis any joint other than the knee such as, but not limited to, the elbow, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA for the treatment of temporomandibular joint disorders is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA for the treatment of acute or chronic pain associated with other single or multiple joints such as, but not limited to, the ankle, elbow, finger, hip, toe, or wrist is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA for the treatment of pelvic diastasis or subluxation is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

MUA involving serial treatment sessions is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

All other uses of MUA are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, manipulation under anesthesia is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

Manipulation under anesthesia (MUA) involves a series of non-invasive mobilization, stretching, and traction procedures while the individual receives anesthesia (e.g., conscious sedation, general anesthesia). Typically, reflex muscle guarding and pain limit the ability of a professional provider to appropriately break up joint and soft tissue adhesions. In addition to reducing the pain associated with treatment, anesthesia induces muscle relaxation and circumvents reflex spasms. This allows improved range of motion (ROM) in restricted axial and appendicular articulations.

Since the 1930s, spinal MUA (SMUA) has been performed by professional providers with the assistance of anesthesiologists. However, complications arising from general anesthesia and high-amplitude manipulation procedures resulted in the decreased use of SMUA. In the 1990s, the advent of safer anesthesia agents allowing for conscious sedation revived interest in MUA-associated procedures. In fact, its use has expanded to include treatment for arthrofibrosis of the knee, chronic adhesive capsulitis (i.e., frozen shoulder), and temporomandibular joint (TMJ) disorders, among other conditions. MUA is typically performed by orthopedic and osteopathic professional providers in an outpatient setting in a hospital or ambulatory surgical center, with the assistance of anesthesiologists as needed. MUA of temporomandibular joint (TMJ) disorders may be performed by oral maxillofacial surgeons.

ACUTE OR TRAUMATIC DISLOCATIONS OR FRACTURES

Joints are susceptible to traumatic injury, which can be typically classified as a dislocation, subluxation, or diastasis. Dislocations involve a complete disruption of a joint with a total loss of contact between the joint's articular surfaces. Subluxations involve joint malalignment, where some of the opposing joint surfaces remain intact. Diastasis is a separation or dislocation between two bones that are attached but have no true joint. The use of MUA is noted as an integral part of the restoration of a fractured or dislocated pelvic ring. MUA has not been established as a treatment option for pelvic subluxation or diastasis.

In the clinical community, MUA is an established treatment option for the closed (i.e., non-surgical) reduction of displaced fractures, as well as acute or traumatic dislocations. Reduction is the positioning of a bone or bones to their normal position after a fracture or dislocation. Reduction is accomplished by applying traction at or across the fracture to relax and lengthen the muscles. Bone fragments are thereby manipulated back into position and are held using a cast or splint. Pressure may be applied to guide the bones into correct position (i.e., manipulation reduction). However, muscle spasm is often difficult to overcome without pain control (e.g., analgesia) and/or sedation. Although many fractures are reduced using sedation or regional anesthesia, individuals may be given general anesthesia to provide pain control and muscle relaxation.

PEER-REVIEWED LITERATURE
In a retrospective study, Betham et al. (2011) compared the effectiveness of procedural sedation in the emergency room with general sedation in the operating room for the manipulation of simple pediatric forearm fractures. Outcome measurements included time from presentation to fracture manipulation, procedure room occupancy, rate of remanipulation, and length of stay. Of the 385 patients presenting with forearm fracture, 108 underwent procedural sedation and 66 underwent MUA under general anesthesia. Time to manipulation was shorter in the procedural sedation group when compared to the general anesthesia group (58 ± 38 minutes vs. 558 ± 368 minutes, respectively, p < 0.0001), as was the length of stay (139 ± 70 minutes vs. 1452 ± 544 minutes, respectively, p < 0.0001). There was no statistically significant difference observed in rates of remanipulation between the two groups (p = 0.305). The authors concluded that MUA under procedural sedation for the treatment of simple closed pediatric forearm fractures was associated with shorter delays to reduction and shorter length of stay when compared with traditional MUA under general anesthesia. The study is limited by its retrospective study design.

In a retrospective study, McKenna et al. (2012) evaluated the effectiveness between pediatric fractures manipulated with conscious sedation (e.g., nitrous oxide) and pediatric fractures manipulated under a general anesthetic. Twenty-eight angulated or displaced nonphyseal forearm fractures were manipulated using conscious sedation, and 27 forearm fractures were manipulated under general anesthesia. The quality of reduction and cast index (how well the cast is molded to the contours of the forearm) were similar between the two groups. There was a statistically significant difference between the need for remanipulation among the children in the conscious sedation group when compared to the need for remanipulation among the children in the general anesthesia group. The authors concluded that despite a higher rate of failure, manipulation of fractures using conscious sedation can achieve an adequate reduction and a high quality of cast. They noted that failures were due to inherently more unstable fracture personalities. The study is limited by its small sample size and the potential heterogeneity of baseline fracture personalities.

ADHESIVE CAPSULITIS (FROZEN SHOULDER)

The joint capsule of the shoulder has ligaments that hold the shoulder bones together. Adhesive capsulitis is a condition associated with loss of shoulder motion and pain. This is typically due to the inflammation of the joint capsule, which prevents the shoulder bones from moving freely in the joint. Adhesive capsulitis occurs in about 2% to 5% of the general population and typically affects individuals between the ages of 40 and 60 years. It occurs more frequently in women than men.

Risk factors may include shoulder injury or surgery, cervical disk disease of the neck, diabetes, and hyperthyroidism. Idiopathic (i.e., resulting from no known cause) adhesive capsulitis typically starts with pain, which prevents movement of the arm. This lack of movement may lead to stiffness, further decreased ROM, and persistent pain.

Conservative treatment typically includes non-steroidal anti-inflammatory medications (NSAIDs) and steroid injections. Combined with physical therapy, ROM may improve in a few weeks, but may take as long as 6 to 9 months for complete recovery. Physical therapy is typically performed on a daily basis. Without treatment, adhesive capsulitis can improve by itself within 3 years, with minimal loss of motion, if any.

Individuals who have had little or no improvement after 6 to 12 weeks of conservative treatment and have intractable, persistent pain may consider MUA, which involves humeral manipulation to disrupt adhesions. The procedure is not recommended in individuals who have had previous MUA with subsequent recurrence or in individuals with osteoporosis or significant osteopenia.

PEER-REVIEWED LITERATURE
In a retrospective study, Flannery et al. (2007) evaluated the influence of the timing of MUA for adhesive capsulitis of the shoulder in 180 consecutive patients. Of these patients, 145 were available for follow-up after a mean of 62 months [12 to 125]. All patients underwent MUA with intra-articular steroid injection. Statistically significant increases in ROM, function, and visual analogue pain scores (VAS) were obtained. Ninety percent of these patients were satisfied with the procedure. Eighty-three percent of the patients had MUA performed less than 9 months from symptom onset, while the remainder had MUA performed after 9 to 40 months. The authors concluded that early intervention patients had a significantly better shoulder function score, though ROM and VAS pain scores did not indicate a statistically significant difference. The study is limited by its retrospective study design and lack of a comparative group control group.

In a retrospective study, Wang et al. (2007) evaluated the effectiveness of MUA for the treatment of idiopathic, post-trauma, and post-surgery adhesive capsulitis. Fifty-one frozen shoulders in 47 patients were evaluated with an adjusted Constant score to assess shoulder function. The Constant score was determined pre-manipulation, at a 3-week follow-up, and at an average of 82-month follow-up. The adjusted pre-manipulation Constant score was a mean of 22.8 ± 4.9 [10 to 31]. The score at 3-week follow-up was 52.6 ± 9.2 [31 to 67] and at a mean of 82 months was 70.1 ± 6.2 [54 to 75]. Twenty-three shoulders scored for a maximum point number of 75 (25 points allocated for muscle strength assessment were excluded from the Constant score scaling). There was a statistically significant difference between the scores at the early and late follow-up end points in the post-surgery group when compared to the idiopathic and post-traumatic groups (p < 0.001). The authors concluded that MUA is a non-invasive procedure that can shorten the course of a self-limiting disease, while improving shoulder function and symptoms within a short period of time. They did note that they found less improvement in post-surgery adhesive capsulitis, especially with respect to residual pain and limited ROM. The study is limited by its retrospective study design and lack of a comparative control group.

In a prospective study, Ng et al. (2009) evaluated the effectiveness of MUA followed by physiotherapy in treating adhesive capsulitis in 86 patients. Of these patients, 58.1% (n=50) completed follow-up. The average age of these patients was 54.5 years, and the mean duration of symptoms until MUA was 13 months. The mean VAS pain scores decreased from 6.07 to 1.88 (p < 0.0005), flexion scores improved from 104.18 to 157.56 (p < 0.0005), abduction scores improved from 70.48 to 150.00 (p < 0.0005), and external rotation scores improved from 13.88 to 45.62 (p < 0.0005). The authors concluded that MUA combined with physiotherapy alleviates pain and facilitates recovery for function in patients with adhesive capsulitis. The study is limited by its small sample size, high loss to follow-up, and a lack of a comparative control group.

In a retrospective study, Sun et al. (2011) evaluated the effectiveness of MUA combined with arthroscopy for the treatment of primary adhesive capsulitis in 34 patients. The average age of the patients was 56 ± 3.6 years [43 to 62], and the course of the disease had a mean time of 11.3 months [9 to 13]. After concurrent arthroscopy and MUA was performed, all patients had postoperative rehabilitation and were followed for an average of 18.9 months [13 to 32]. ROM and pain score outcomes were obtained. At 12-month follow-up, patients had a statistically significant decrease in pain (p < 0.01) and an increase in their ROM (p < 0.05). The authors concluded that MUA combined with arthroscopy is an effective and minimally invasive treatment for primary adhesive capsulitis. The study is limited by its retrospective study design, small sample size, and lack of a comparative control group.

In a comparative study, Vastamaki et al. (2012) evaluated the natural history of idiopathic adhesive capsulitis. Eighty-four shoulders in 83 patients, with a mean age of 53 years, were treated for a mean follow-up of 9 years [2 to 27]. Fifty-one patients were untreated, 32 received non-operative treatments (e.g., NSAIDs), and 20 underwent MUA. The mean age of MUA patients was 49 years, and the mean follow-up was 14 years [2 to 24]. Outcome measurements included duration of disease, pain levels, and ROM. The duration of disease was an average of 15 months [4 to 36] in the untreated group and 20 months [6 to 60] in the non-operative group. At last follow-up, ROM improved to 94% in the untreated group, 91% in the non-operative group, and 91% in the MUA group. Fifty-one percent of patients in the untreated group, 44% in the non-operative group, and 30% in the MUA group were completely pain-free at rest, during the night, and with exertion. The authors’ primary conclusions indicated that a high majority of patients with spontaneous adhesive capsulitis recovered to normal levels of function without treatment. The study is limited by its retrospective study design, small sample size, and heterogeneity in comparison groups.

In a systematic review, Maund et al. (2012) evaluated the clinical effectiveness of treatments for primary adhesive capsulitis. Thirty-one clinical effectiveness studies were included in their evaluation. In addition to MUA, steroid injection, sodium hyaluronate, supervised neglect, physical therapy, acupuncture, distention, and capsular release treatments were evaluated. Specific to MUA, the authors identified 4 randomized controlled trials (RCTs) for the treatment of primary adhesive capsulitis. Each of these 4 RCTs had different comparison designs, which ranged from comparing the effectiveness of MUA to physical therapy alone to comparing the effectiveness of two different MUA techniques. The authors concluded that there was limited clinical evidence on the effectiveness of MUA for primary adhesive capsulitis and that further high-quality research was required. The authors noted that these conclusions were due to the nature of its included and available studies, which primarily consisted of retrospective case series.

ARTHROFIBROSIS

Arthrofibrosis is a condition that can afflict joints that have been recently injured or operated upon. A traumatic stimulus leads the joint to form extensive, internal scar tissue, which is followed by shrinkage and tightening of the joint capsule. This tightening process may continue to the point where ROM is restricted, and afflicted individuals may lose the ability to straighten or bend the joints.

Conservative treatment for arthrofibrotic joints includes aggressive stretching, physical therapy exercises, and NSAIDS. For patients with refractory persistent and intractable pain, MUA is considered as a treatment option so the restrictive, internal scar tissue is torn by forcing the joints to fully bend and straighten under anesthesia.

ELBOW
Peer-Reviewed Literature

In a retrospective study, Tan et al. (2006) evaluated the outcome of elbow release for the treatment of 52 patients with post-traumatic elbow stiffness. The mean age of the group was 35.1 years, and follow-up was a mean of 18.7 months. Specific to MUA, 27% of the patients (n=14) underwent closed manipulation in the early postoperative period. Complications to elbow release included wound infection (n=3), cubital tunnel syndrome (n=3), and reflex dystrophy (n=1). The authors concluded that the recurrence of elbow stiffness in the postoperative period is common, but MUA and repeat releases may be effective. The study is limited by its retrospective study design, small sample size, and lack of a comparative control group. Furthermore, due to the design of this study, the authors’ conclusions cannot be generalizable to patients undergoing MUA for the treatment of post-traumatic elbow stiffness.

In a retrospective study, Araghi et al. (2010) evaluated MUA for the treatment of 44 patients with limited articulation in the elbow. Follow-up occurred at a minimum of 12 months and revealed an improvement to 73º from a baseline arc of 33º. Three patients had no appreciable change (< 10º) in the total arc, and 1 patient lost motion. Four patients underwent a second manipulation at a mean of 119 days after the first manipulation. Complications included worsening of the ulnar paresthesias in 3 patients, with 2 patients resolving their complications spontaneously, and 1 patient requiring anterior ulnar nerve transposition. The authors concluded that MUA for the elbow could be a valuable adjunctive procedure to help regain motion. However, they noted that additional studies should be conducted. The study is limited by its retrospective study design, small sample size, and lack of a comparative control group.

KNEE
Peer-Reviewed Literature

In a retrospective study, Keating et al. (2007) evaluated the effectiveness of MUA for patients who failed to achieve greater than 90 degrees of flexion following total knee arthroplasty (TKA). One hundred and thirteen knees in 90 patients underwent MUA and were followed at 6 months, and at 1, 3, and 5 years postoperatively. Ninety percent of the 90 patients (n=81) achieved improvement of knee flexion following MUA. The average flexion was 102º prior to TKA, 111º following skin closure, and 70º before MUA. The average improvement in flexion from the measurement made before MUA was 35º at 5-year follow-up (p < 0.0001). There was no statistically significant difference in the mean improvement in flexion among patients who had MUA within 12 weeks postoperatively when compared with those who had MUA more than 12 weeks postoperatively. The authors concluded that MUA generally increases flexion following TKA and those patients with severe preoperative pain are more likely to require MUA. The study is limited by its retrospective study design, small sample size, and lack of a comparative control group.

In a retrospective study, Mohammed et al. (2009) evaluated the effectiveness of MUA for 21 patients with knee stiffness following partial or TKA. The average age of the patients was 62 years [56 to 80]. The mean duration between knee arthroplasty was 13.2 weeks [6 to 32]. ROM was analyzed pre- and post-MUA and at a subsequent follow-up. ROM improved from a mean of 60.2º [40 to 80] pre-MUA to 91.9º [45 to 120] post-MUA. The mean improvement was 31.6º (p < 0.0001). At an average follow-up of 3 months [6 weeks to 8 months], the mean arc of motion was 90.4º [40 to 120]. The authors concluded that MUA has a role in the treatment of early stiffness following knee arthroplasty and results in immediate outcomes. The study is limited by its retrospective study design, small sample size, and lack of a comparative control group.

In a systematic review, Fitzsimmons et al. (2010) evaluated the outcome of three treatment modalities for arthrofibrosis that developed subsequent to a TKA. These treatment modalities included MUA, arthroscopy, and open arthrolysis. The authors included 14,421 studies, of which 23 were deemed relevant. ROM was the main outcome measurement. The gains in ROM after MUA and arthroscopy (with or without MUA) were similar, though open arthrolysis appeared to have inferior gains in ROM. The number of clinically important complications after MUA and arthroscopy (with or without MUA) were similar. The authors concluded that TKA can be improved with MUA and/or arthroscopy, with few complications. The study is limited by the included heterogeneous studies, which were retrospective in design.

In a systematic review, Ghani et al. (2012) evaluated the outcome of four main modalities of treatment for arthrofibrosis that developed subsequent to a TKA. These treatment modalities included MUA, arthroscopic debridement, open surgical release, and revision TKA. A total of 25 studies were selected, representing 798 patients. Two studies were prospective in design, while the remainder was retrospective in nature. The primary outcome measures assessed were ROM and knee scores. MUA had a mean increase of 38.4º, arthroscopic release had a mean increase of 36.2º, open surgical release had a mean increase of 43.4º, and revision TKA had a mean increase of 24.7º. Analysis indicated that there were no statistically significant differences between the four treatment modalities. The authors concluded that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery subsequent to TKA. The study is limited by its included heterogeneous studies, which were mainly retrospective in design.

CHRONIC SPINAL PAIN

Pain-related conditions involving the spine are typically treated over the course of several weeks with chiropractic care, physical therapy, or steroid injections. SMUA is a proposed treatment to manage persistent, intractable pain that is refractory to conservative treatment. After sedation is achieved, a series of mobilization, stretching, and traction procedures are performed on the spine and lower extremities. This may include passive stretching of the gluteal and hamstring muscles with straight-leg raises and hip capsule stretching. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrusts applied to the spinous process by hand, while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area to address lower back pain.

SMUA typically takes 15 to 20 minutes and, after recovery from anesthesia, individuals are discharged with instructions to remain active, while using heat or ice for short-term analgesic control. Care after SMUA may include 4 to 8 weeks of active rehabilitation, which may involve additional SMT. SMUA has also been performed after injection of local anesthetic into the lumbar zygapophyseal and/or sacroiliac joints under fluoroscopic guidance and after epidural injection of corticosteroids.

PEER-REVIEWED LITERATURE
In a literature review, Kohlbeck and Haldeman (2002) indicate that there has been an increase in utilization of spinal manipulation as a method to treat select patients with spinal pain. The authors identified four categories of medication-assisted manipulation, including MUA under epidural anesthesia or sedation, under epidural anesthesia with or without epidural steroid injection, under joint anesthesia/analgesia, and with injections such as steroids or proliferant agents. The literature consisted primarily of case reports or series, two RCTs and one cohort study. The authors concluded that despite a relatively long history of clinical use that spans over 70 years, the evidence to support the effectiveness of SMUA remains largely anecdotal. However, they noted that there was sufficient theoretical basis and positive results from some case series to warrant further controlled trials.

In a prospective comparative study, Palmieri and Smoyak (2002) evaluated the efficacy of using self-reported questionnaires to study MUA for 87 patients with chronic lower back pain. The intervention group consisted of 38 patients and the non-intervention group consisted of 49 patients. Patient selection was determined from a convenience sample. Outcome measurements included a numeric pain scale and a disability score. The average numeric pain scale scores in the MUA group decreased by 50% and the average disability scores decreased by 51%, while the non-intervention group had decreases of 26% and 38%, respectively. The authors concluded that self-reported outcomes improved after the procedure and that those patients in the MUA group had better improvements. They noted that larger scale studies were needed to support the effectiveness of SMUA for the treatment of chronic lower back pain. The study is limited by its small sample size and design, particularly as it utilized a convenience sample and its primary purpose was to evaluate the effectiveness of using self-reported questionnaires. Furthermore, there were no statistically significant or clinically meaningful differences between the MUA and non-intervention groups.

In a prospective cohort study, Kohlbeck et al. (2005) evaluated the effectiveness of MUA for the treatment of chronic lower back pain when compared to SMT alone. Sixty-eight patients with chronic lower back pain received an initial 4- to 6-week trial of SMT, after which 42 patients received supplemental MUA, while the remaining 26 patients continued with SMT. Outcome measurements included changes in pain and disability. At 3-month follow-up, lower back pain and disability scores favored the MUA group over the SMT-only group (mean difference of 4.4 points, 95% CI: -2.2 to 11.0). The difference attenuated at 1-year follow-up (mean difference of 0.3 points, 95% CI: -8.6 to 9.2). The relative odds of experiencing a 10-point improvement in pain and disability scores favored the MUA group at 3-month follow-up (OR: 4.1, 95% CI: 1.3 to 13.6) and at 1-year follow-up (1.9, 95% CI: 0.6 to 6.5). The authors concluded that MUA appears to offer some patients increased improvement in lower back pain and disability. They noted that further investigation of these benefits should be conducted in an RCT. The study is limited by its small sample size. Moreover, the results indicate that mean differences in lower back pain and disability scores are not statistically significant. In addition, from 3-month to 1-year follow-up, any discerned differences are attenuated and their statistical significance may be in question.

TEMPOROMANDIBULAR JOINT DISORDERS

The TMJ connects the temporal bone of the skull with the mandible (jaw) by an articulating condyloid process. The joint is cushioned by a layer of cartilage and by a disc that lies between the articulating surfaces. The disc adds stability and acts as a shock absorber. TMJ disorders typically arise from traumatic injuries, internal derangements, dislocations, ankylosis (joint stiffness due to abnormal adhesion), arthritis, neoplasms, and congenital and developmental abnormalities.

PEER-REVIEWED LITERATURE
In a prospective study, Foster et al. (2000) evaluated the effectiveness of MUA under general anesthesia for the treatment of TMJ disorder. Fifty-five patients were invited to participate in the study, with only 65% (n=36) participating. Of these, 15 patients improved, 15 did not, and 6 showed partial improvement. The median pre-treatment opening of the mandible was 20 mm [13 to 27]. Among those who improved after manipulation, the median post-treatment opening of the mandible was 38 mm [35 to 56]. Some patients who improved post-treatment experienced a return of TMJ clicking, but not of joint or muscle tenderness. The authors concluded that MUA under general anesthesia may help some patients. The study is limited by its small sample size and short-term follow-up period. Poor study design may limit the generalizability of the results, which are hindered by low participation rates and primary outcome conclusions, which compared two distinct stratifications (median pre-treatment opening of the entire cohort vs. median post-treatment opening of only patients who improved).

GUIDELINES

In 2002, the National Academy of Manipulation Under Anesthesia Physicians published guidelines to provide the recommendations for MUA. They indicated that MUA is clinically justified for individuals that respond favorably to conservative treatment for a 2- to 6-week period, but continue to experience intractable pain or biomechanical dysfunction. Diagnosed conditions must fall within recognized categories of conditions that are responsive to MUA. Serial MUA (more than one treatment session) was recommended when conservative care has been rendered, the injury is recurrent, and fibrotic tissue and articulator fixation prevents a single MUA session from being effective.

In 2002, the International Chiropractors Association indicated that anesthesia is inappropriate and unnecessary to the delivery of a chiropractic adjustment.

In 2006, the American Chiropractic Association (ACA) indicated that MUA procedures are appropriate in a select patient population. In an ACA article, it was noted that MUA should be limited to individuals with specific neuro-musculoskeletal conditions that have failed to respond to conservative management, are chronic and recurrent, cause disability that has been shown to respond to MUA, or have severe symptoms that could be temporarily relieved by MUA. In addition, the individual should be medically cleared for toleration to sedation. Noted adverse events include vascular, muscular, ligamentous, and osseous damage, anaphylaxis, respiratory and cardiac failure, coma, and death.

In 2008, the American College of Occupational and Environmental Medicine (ACOEM) published guidelines which addressed the evaluation and management of common disorders among workers, including chronic lower-back pain. They indicated that based on an insufficiency of evidence, spinal MUA was not recommended due to the high potential for harm to the patient. With respect to knee disorders, the ACOEM recommended MUA for select postoperative patients with significantly reduced ROM because the intervention had limited potential for harm and constitutes best practices to treat and restore knee function. They did note that the current literature is too limited to support an evidence-based recommendation.

In 2008 and in a subsequent 2011 update, the Work Loss Data Institute published guidelines which addressed the evaluation and management of acute and chronic shoulder pain. They indicated that MUA was not recommended for the treatment of acute and chronic conditions related to the forearm, wrist, and hand; hip and pelvis; knee and leg; and shoulder.

SUMMARY

The evidence in the available published peer-reviewed literature indicates that MUA is safe and effective for a select patient population with specific indications, including the reduction of acute or traumatic dislocations and displaced fractures. When an individual has intractable, persistent pain refractory to conservative treatment (e.g., medical management, physical therapy), MUA may be indicated for individuals with arthrofibrosis of the knee following trauma or knee surgery (e.g., TKA) and adhesive capsulitis of the shoulder.

There is a lack of adequate evidence in the published peer-reviewed literature and a lack of consensus among professional societies to support the effectiveness of SMUA for the treatment of spine-related chronic pain or MUA for the treatment of arthrofibrosis of any joint other than the knee (e.g., elbow). The available studies are limited in their design and small sample size. Specific to SMUA, many of the reported conclusions indicate that there were no statistically significant or clinically meaningful differences in pain or disability between SMUA and conservative treatment. Additionally, the most common serious adverse events associated with SMUA include disk herniation, cauda equine syndrome, and vertebrobasilar accidents, which may not resolve despite subsequent treatment.

There is limited evidence, if any, to support the effectiveness of MUA for the treatment of adhesive capsulitis of any joint other than the shoulder (e.g., hip), TMJ disorders, or acute or chronic conditions related to, but not limited to, the ankle, elbow, finger, hip, toe, or wrist. Additionally, the use of MUA in treating multiple body joints or in serial treatment sessions has not been established due to the paucity of published peer-reviewed literature and a lack of consensus from professional society guidelines.
References


American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. American Academy of Osteopathy J. 2005; 15(2):26-27.

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):202-8.

Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low-back pain. The Cochrane Database of Systematic Reviews 2005 Issue 4. In: The Cochrane Library, Issue 4, 2005.

Betham C, Harvey M, Cave G. Manipulation of simple paediatric forearm fractures: a time-based comparison of emergency department sedation with theatre-based anaesthesia. N Z Med J. 2011;124(1344):46-53.

Cremata E, Collins S, Clauson W, et al. Manipulation under anesthesia: a report of four cases. J Manipulative Physiol Ther. 2005;28(7):526-33.

Degenais S, Mayer J, Wooley JR, et al. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J. 2008;8(1):142-9.

Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap.2013; 21(1):14.

Dougherty P, Bajwa S, Burkke J, et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther. 2004; 27(7):449-56.

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):537-46.

Dudek N, Trudel G. Joint contractures. In: Frontera: Essentials of Physical Medicine and Rehabilitation. 2nd ed. Ch 117. 2008; Saunders.

Farrell CM, Sperling JW, Cofield RH. Manipulation for frozen shoulder: long term results.
J Shoulder Elbow Surg. 2005;14(5):480-4.

Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review. Clin Orthop Relat Res. 2010;468(4):1096-106.

Flannery O, Mullet H, Colville J. Adhesive shoulder capsulitis: does the timing of manipulation influence outcome?. Acta Orthopaedica Belgica. 2007;73(1):21-5.

Foster ME, Gray RJ, Davies SJ, Macfarlane TV. Therapeutic manipulation of the temporomandibular joint. Br J Maxillofac Surg. 2000;38(6):641-644.

Ghani H, Maffulli N, Khanduja V. Management of stiffness following total knee arthroplasty: a systematic review. Knee. 2012;19(6):751-9.

Gordon R, Cremata E, & Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropractic & Manual Therapies. 2014;22(7).

Griffen LY. Frozen shoulder. In: DeLee: DeLee and Drez’s Orthopaedic Sports Medicine. 2nd ed. Ch 13, The female athlete.

Keating EM. Ritter MA. Harty LD. et al. Manipulation after total knee arthroplasty. J Bone Joint Surg. 2007;89(2):282-6.

Kivimäki J, Pohjolainen T, Malmivaara A, et al. Manipulation under anesthesia with home exercises versus home exercises alone in the treatment of frozen shoulder: a randomized, controlled trial with 125 patients. J Shoulder Elbow Surg. 2007;16(6):722-6.

Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 20002;2(4):288-302.

Kohlbeck FJ, Haldeman S, Hurwitz E,L et al. 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):245-52.

Looney CG, Raynor B, Lowe R. Adhesive capsulitis of the hip: a review. J Am Acad Orthop Surg. 2013;21(12):749-55.

Luukkainen R, Sipola E, Varjo P. Successful treatment of frozen hip with manipulation and pressure dilatation. Open Rheumatol J. 2008;2:31-2.

Magit D, Wolff A, Sutton K, et al. Arthrofibrosis of the knee. J Am Acad Orthop Surg. 2007;15(11):682-94.

Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1-264.

McKenna P, Leonard M, Connolly P, et al. A comparison of pediatric forearm fracture reduction between conscious sedation and general anesthesia. J Orthop Trauma. 2012;26(9):550-5.

Mercier LR. Frozen shoulder. In Ferri: Ferri’s Clinical Advisor 2007: Instant Diagnosis and Treatment. 9thed. 2007.

Michaelson MR. Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin. J Manipulative Physiol Ther. 2000;23(2):127-9.

Mohammed R, Syed S, Ahmed N. Manipulation under anaesthesia for stiffness following knee arthroplasty. Ann R Coll Surg Engl. 2009;91(3):220-3.

Mun, SW, Baek, CH. Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study. J Shoulder Elbow Surg. (2016);25:1937–1943.

Namba RS, Inacio M. Early and late manipulation improve flexion after total knee arthroplasty. J Arthroplasty. 2007;22(6 Suppl 2):58-61. Epub 2007 Jul 26.

Nesterenko S, Sanchez-Sotelo J, Morrey BF. Refractory elbow arthrofibrosis. A report of four cases. J Bone Joint Surg Am. 2009;91(11):2693-5.

Ng CY, Amin AK, Narborough S, et al. Manipulation under anesthesia and early physiotherapy facilitate recovery of patients with frozen shoulder syndrome. Scott Med J. 2009;54(1):29-31.

Nirschl RP, Willett SG. Adhesive capsulitis. In: Frontera: Essentials of Physical Medicine and Rehabilitation. 1st ed. Ch 12. 2002.

Paley D. Principles of deformity correction. In: Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction. 3rd ed. Ch 62;. 2003; Saunders.

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.

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;15:221-4.

Peterson CK, Humphreys BK, Vollenweider R, et al. Outcomes for chronic neck and low back pain patients after manipulation under anesthesia: a prospective cohort study. J Manipulative Physiol Ther. 2014;37(6):377-382.

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):1197-200.

Sheridan MA, Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37(4):531-9.

Sun J, Zhang L, Liu JS, et al. Treatment of frozen shoulder with manipulation under anesthesia combined with arthroscopy. Zhongguo Gu Shang. 2011;24(6):490-2.

Tan V, Daluiski A, Simic P, Hotchkiss RN. Outcome of open release for post-traumatic elbow stiffness. J Trauma. 2006;61(3):673-8.

Vastamki H, Kettunen J, Vastamki M. The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study. Clin Orthop Relat Res. 2012;470(4):1133-43.

Vezeridis PS, Goel DP, Shah AA, et al. Postarthroscopic arthrofibrosis of the shoulder. Sports Med Arthrosc. 2010;18(3):198-206.

Wang JP, Huang TF, Hung SC, et al. Comparison of idiopathic, post-trauma and post-surgery frozen shoulder after manipulation under anesthesia. Int Orthop. 2007;31(3):333-7.

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.

Work Loss Data Institute. Hip & pelvis (acute & chronic). Encinitas. CA: Work Loss Data Institute; 2011.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

23700, 27570, 23655, 26675, 26705, 26775, 27198, 27257, 27825

EXPERIMENTAL/INVESTIGATIONAL

21073, 22505, 24300, 25259, 26340, 27275, 27860

MANIPULATION UNDER ANESTHESIA FOR USE IN THE TREATMENT OF SINGLE OR MULTIPLE JOINTS FOR PAIN MANAGEMENT AND FOR THE USE OF SERIAL TREATMENTS IS CONSIDERED EXPERIMENTAL/INVESTIGATIONAL.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.14.24b:
04/30/2018The policy has undergone a routine review, and the following procedure codes have been added: 27198

The following procedure code has been termed from this policy: 27194

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 04/30/2018
Version Issued Date: 04/30/2018
Version Reissued Date: N/A

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.