Medical Policy


Subject:Manipulation Under Anesthesia of the Spine and Joints other than the Knee
Policy #:  MED.00079Current Effective Date:  07/15/2014
Status:ReviewedLast Review Date:  05/15/2014

Description/Scope

This document addresses the use of manipulation under anesthesia (MUA) for joints other than the knee and spinal manipulation under anesthesia (SMUA). SMUA has been proposed as a treatment for individuals with chronic back pain, other musculoskeletal disorders, vertebral fracture, complete dislocation or incomplete dislocation (also referred to as subluxation).

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

Position Statement

Medically Necessary:

Manipulation under anesthesia (MUA) of the shoulder is considered medically necessary for adhesive capsulitis (frozen shoulder).

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

Investigational and Not Medically Necessary:

Manipulation under anesthesia (MUA) of the shoulder is considered investigational and not medically necessary for all other diagnoses not listed above.

Spinal manipulation under anesthesia (SMUA) is considered investigational and not medically necessary for all other diagnoses not listed above.

Manipulation under anesthesia (MUA) of any other joint not listed above as medically necessary, except for the knee, is considered investigational and not medically necessary.

Rationale

Shoulder
Adhesive capsulitis is a condition of shoulder stiffness and pain that leads to the restriction of shoulder movement (frozen shoulder). It is frequently associated with  an injury or medical procedure that leads to lack of limb use secondary to pain. Adhesions grow between the joint surfaces and cause the restricting motion. The shoulder joint becomes so stiff and tight that it is difficult to do simple movements such as raising the arm. Treatment entails restoring joint movement and reducing the shoulder pain. Therapy includes medications,  stretching exercises, physical therapy and steroid injections. If conservative treatment fails, MUA may be necessary. This involves putting an individual to sleep and forcing the shoulder to move, causing the adhesions to stretch and tear.

Dodenhoff (2000) assessed 43 shoulders of 39 individuals who were treated with MUA for a diagnosis of frozen shoulder. Four individuals were not available for follow-up, therefore leaving 39 shoulders of 37 individuals for assessment. At the initial 3 to 6 week follow-up, the range of movement had improved to medians of 120 degrees abduction, 50 degrees of external rotation, and 60 degrees of internal rotation. Improvement was maintained for a mean follow-up of 11 months following the procedure. Overall, 94% of the individuals were satisfied with their procedure.

Ng (2009) reported on MUA of 86 individuals with frozen shoulder. Complete data was available for 50 of the individuals. Of the 50 who form the basis of the study, 1 participant had an increase in shoulder pain, 3 participants had pain levels that remained the same and 46 participants reported an improvement in pain level six weeks following the MUA. The investigators noted limitations for this study and stated "the lack of an untreated control group, a short period of follow-up and a significant number of patients who defaulted from follow-up represent limitations of our study." When the clinicians made attempts to contact individuals when they failed to attend the six week visit, most of them reported alleviation of their shoulder symptoms such that they thought further visits were unnecessary.

Farrell and colleagues (2005) studied the longer-term effects following MUA for adhesive capsulitis of the shoulder. Nineteen shoulders were followed for an average of 15 years following MUA. Thirteen shoulders had no pain, 3 had slight pain, 2 had occasional moderate pain and 1 had moderate pain. Range of motion improved to a mean of 70 degrees in elevation and external rotation of 53 degrees. All 19 individuals felt their shoulder was stable.

A literature review by Grant and colleagues (2013) looked at whether there is a difference in the clinical effectiveness of arthroscopic capsular release compared to MUA for adhesive capsulitis. There were 9 MUA studies and 17 capsular release studies that were evaluated. The authors concluded that evidence quality is low (definitions, timing and outcomes inconsistent) so that the data available demonstrates no clear difference between a capsular release and an MUA.

Spine
SMUA is considered an established treatment option for vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine and will not be discussed further. Therefore, this discussion will focus on SMUA as a treatment of chronic back pain, other musculoskeletal disorders and the pain associated with incomplete dislocation.

As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. In a case series, West and colleagues (1999) reported on 177 individuals with acute and chronic back pain who had failed prior therapy. The individuals were treated with three sequential manipulations under intravenous sedation, followed by 4 to 6 weeks of further chiropractic spinal manipulation. At the 6-month follow- up, there was a 60% improvement in visual analog scale scores. However, this uncontrolled study cannot isolate the contribution of the SMUA; treatment effect could also be related to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition. Palmieri and Smoyak (2002) evaluated the efficacy of MUA using a self-reported pain questionnaire in a convenience sample of those undergoing spinal manipulation compared to conventional chiropractic treatment. The pain scales decreased by 50% in those treated with SMUA compared to a 26% decrease in those receiving conventional treatment. The lack of a true control group limits interpretation of this study. Similarly, this literature does not permit scientific interpretation.

In a prospective cohort study of 68 individuals with chronic low-back pain, Kohlbeck and colleagues (2005) measured changes in pain and disability for those with LBP who received spinal manipulation with intravenous analgesia and sedation and compared these to changes in a group only receiving spinal manipulation. Individuals with pain caused by a fracture were excluded. All individuals received an initial 4 to 6-week trial of spinal manipulation, after which 42 individuals received supplemental SMUA and the remaining 26 individuals continued with spinal manipulation without anesthesia. Low back pain and disability measures favored the SMUA group over the spinal manipulation only group at 3 months. This difference narrowed at 1 year. The investigators concluded SMUA appears to offer some improvement in low back pain and disability. However, the investigators noted, "improvements may not endure," and "the clinical changes observed are not necessarily caused by SMUA and large randomized controlled trials are necessary to determine effectiveness." 

At this time, there is insufficient evidence from the available peer-reviewed literature to conclude that SMUA in the absence of vertebral fracture or complete dislocation is an effective treatment for pain.

Other Joints
MUA has also been suggested as a treatment for other joints such as the elbow, wrist, hand, finger, pelvis and ankle. A search of peer-reviewed literature finds retrospective chart reviews, small sample sizes and single case series. There are no controlled studies or any studies reporting long-term follow-up with outcomes. At this time there is insufficient evidence in peer-reviewed medical literature to establish and support the use of MUA for other joints such as the elbow, wrist, hand, finger, pelvis and ankle.

Background/Overview

Manipulation refers to the use of a variety of manual techniques to adjust the spinal column and joints, improve the range of motion of the joints, stretch and relax connective tissue and muscles, and promote overall relaxation. It can be used in conjunction with anesthesia. With anesthesia, the individual is less apprehensive and the anesthesia allows for reduced muscle tone and protective reflex mechanisms. This is known as MUA.

Adhesive capsulitis of the shoulder (frozen shoulder) has customarily been thought of as a self-resolving condition which can last for years. The etiology is unknown. It is characterized by a painful restriction of both passive and active range of motion. The overall goal is to relieve pain and restore motion by conservative measures such as anti-inflammatory medications, injections and physical therapy. In an attempt to decrease recovery time and improve function, manipulation of the shoulder under anesthesia has been used to shorten that time span and improve functional range of motion.

SMUA may be performed in two general settings; for example, as a closed treatment of vertebral fracture or complete dislocation, or as a form of treatment of the pain associated with incomplete dislocation, that is, subluxation. In the latter setting, spinal manipulation or adjustment under anesthesia is intended to overcome the conscious individual's protective reflex mechanisms, which may limit the success of spinal manipulation in the conscious individual. While general anesthesia is typically used for the closed treatment of vertebral fracture or complete dislocations, spinal manipulation for the treatment of incomplete dislocations typically uses either conscious sedation or regional anesthesia. A low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique used in the typical spinal adjustment in the conscious individual.

SMUA has been proposed as a treatment modality for spinal dysfunction. This procedure is typically performed in one 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.

Definitions

Adhesive capsulitis (frozen shoulder): A condition of capsular thickening or tightening associated withprolonged immobility of the shoulder which causes pain, stiffness and limited range of motion.

Dislocation: The displacement of a bone from its normal position, which can be classified as either complete or incomplete. This distinction may be made with imaging studies.

Subluxation: A condition in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. This is also known as a partial or incomplete dislocation.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Shoulder
When services are Medically Necessary:

CPT 
23700Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
726.0Adhesive capsulitis of shoulder
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
M75.00-M75.02Adhesive capsulitis of shoulder

When services are Investigational and Not Medically Necessary:
For the procedure code listed above for all other diagnoses; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Spine
When services are Medically Necessary:

CPT 
22505Manipulation of the spine requiring anesthesia, any region
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
805.00-805.9Fracture of vertebral column without mention of spinal cord injury
806.00-806.9Fracture of vertebral column with spinal cord injury
V54.17Aftercare for healing traumatic fracture of vertebrae
V54.27Aftercare for healing pathologic fracture of vertebrae
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
S12.000A-S12.691SFracture of cervical vertebra
S22.000A-S22.089SFracture of thoracic vertebra
S32.000A-S32.2XXSFracture of lumbar vertebra, sacrum, coccyx

When services may be Medically Necessary when criteria are met:

CPT 
22505Manipulation of the spine requiring anesthesia, any region
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
839.00-839.59Other, multiple, and ill-defined dislocations, vertebra [when specified as complete dislocation or acute traumatic incomplete dislocation]
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses when specified as complete dislocation or acute traumatic incomplete dislocation
S13.100A-S13.4XXSSubluxation and dislocation of cervical vertebrae and neck
S23.100A-S23.171SSubluxation and dislocation of thoracic vertebra
S33.100A-S33.39XSSubluxation and dislocation of lumbar vertebra, sacroiliac and sacrococcygeal joint

When services are Investigational and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, for all other diagnoses; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Other joints (excluding knee)
When services are Investigational and Not Medically Necessary:

CPT 
24300Manipulation, elbow, under anesthesia
25259Manipulation, wrist, under anesthesia
26340Manipulation, finger joint, under anesthesia, each joint
27275Manipulation, hip joint, requiring general anesthesia
27860Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Dodenhoff RM, Levy O, Wilson A, Copeland SA. Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity. J Shoulder Elbow Surg. 2000; 9(1):23-26.
  2. Farrell CM, Sperling JW, Cofield RH. Manipulation for frozen shoulder: long-term results. J Shoulder Elbow Surg. 2005; 14(5):480-484.
  3. Grant JA, Schroeder N, Miller BS, Carpenter JE. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. J Shoulder Elbow Surg. 2013; 22(8):1135-1145.
  4. Hamdan TA, Al-Essa KA. Manipulation under anaesthesia for the treatment of frozen shoulder. Int Orthop. 2003; 27(2):107-109.
  5. 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.
  6. Ng CY, Amin AK, Narborough S, McMullan L, et al. Manipulation under anaesthesia and early physiotherapy facilitate recovery of patients with frozen shoulder syndrome. Scott Med J. 2009; 54(1):29-31.
  7. Palmieri NF, Smoyak S. Chronic low back pain: A study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther. 2002; 25:E8-E17.
  8. Sheridan MA, Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006; 37(4):531-539.
  9. 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):333-337.
  10. 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.
Index

Manipulation under Anesthesia
Spinal Manipulation under Anesthesia

Document History
StatusDateAction
Reviewed05/15/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, Background/Overview and References.
Reviewed05/09/2013MPTAC review. Updated Description/Scope.
Reviewed05/10/2012MPTAC review. Updated Index.
Reviewed05/19/2011MPTAC review. Updated Rationale and References.
Revised05/13/2010MPTAC review. Title change from "Spinal Manipulation Under Anesthesia" to "Manipulation under Anesthesia of the Spine and Joints other than the Knee." Addition of medically necessary statement "Manipulation under anesthesia (MUA) of the shoulder is considered medically necessary for adhesive capsulitis (frozen shoulder)." Clarification of medically necessary statement for MUA of the spine from "Spinal manipulation under anesthesia for the treatment of vertebral fracture or complete dislocation is considered medically necessary" to "Spinal manipulation under anesthesia (SMUA) is considered medically necessary for the treatment of vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine." Addition of not medically necessary statement "Manipulation under anesthesia (MUA) of the shoulder is considered investigational and not medically necessary for all other diagnoses not listed above." Clarification of not medically necessary statement for MUA of the spine from "All other indications of spinal manipulation under anesthesia, in the absence of vertebral fracture or complete dislocation are considered investigational and not medically necessary, including, but not limited to incomplete dislocation (i.e., subluxation)" to "Spinal manipulation under anesthesia (SMUA) is considered investigational and not medically necessary for all other diagnoses not listed above." Addition of not medically necessary statement "Manipulation under anesthesia (MUA) of any other joint not listed above as medically necessary, except for the knee, is considered investigational and not medically necessary." Updated Description/Scope, Rationale, Background/Overview, Definitions, Coding and Reference sections.
Reviewed08/27/2009MPTAC review. No change to Position Statement.
Reviewed08/28/2008MPTAC review. Updated References.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed08/23/2007MPTAC review. Medically necessary statement clarified.
Reviewed09/14/2006MPTAC review. Rationale updated. No change in position.
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review
Date
Document
Number
Title
Anthem, Inc. No prior document 
WellPoint Health Networks, Inc.06/24/20042.07.11Spinal Manipulation Under Anesthesia