In the appendicular skeleton, manipulation with the patient under anesthesia (MUA) may be performed as a treatment of arthrofibrosis, particularly of the shoulder (i.e., frozen shoulder) or knee. In the spine, manipulation under anesthesia may be performed as a closed treatment of vertebral fracture or dislocation. This policy does not address the treatment of vertebral fractures or dislocations. In the absence of vertebral fracture or dislocation, MUA, performed either with the patient sedated or under general anesthesia, may be performed as a treatment of subluxation and is intended to overcome the conscious patient's protective reflex mechanism, which may limit the success of prior attempts of spinal manipulation or adjustment in the conscious patient. In MUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical spinal adjustment. A single session of MUA may be offered, followed by a series of outpatient sessions, or a series of up to 5 sessions of MUA may be offered, also followed by outpatient sessions. In some instances the MUA may be accompanied by corticosteroid injections.

Spinal manipulation under anesthesia, in the absence of vertebral fracture or dislocation, is considered investigational.

Dislocation versus Subluxation

Spinal manipulation under anesthesia is frequently performed for chronic low back pain related to subluxation, considered investigational, according to the above policy; therefore, a distinction must be made between subluxation and dislocation. According to the chiropractic literature, a subluxation can be defined as a restriction or loss of normal range of motion of the joint causing dysfunction of the spinal motion segment or peripheral joints. A dislocation can be defined as a disruption in the joint integrity. Typically, a subluxation cannot be detected with imaging studies, while a dislocation can.

Coding Issues

CPT

CPT code 22505 explicitly identifies spinal manipulation under anesthesia. According to the CPT Assistant, codes having the descriptor "requiring anesthesia" mean requiring general anesthesia. Therefore, use of CPT code 22505 in conjunction with conscious sedation or regional anesthesia is an inappropriate use of the code. In these instances, CPT codes for chiropractic manipulative treatment (98940-98942) may be used.

When general anesthesia is used, the following anesthesia code would be reported:

00640: Anesthesia for manipulation of the spine or for closed procedures on cervical, thoracic, or lumbar spine.

CPT code 22315 describes closed treatment of vertebral fractures and/or dislocations with or without anesthesia, by manipulation or traction. However, this policy does NOT address the treatment of vertebral fractures or dislocations by manipulation under anesthesia.

ICD-9

The currently available ICD-9 codes do not adequately distinguish between subluxation and dislocation. Chiropractors have used ICD-9 739 (nonallopathic lesion, not otherwise classified) to code for subluxations. This code specifically includes segmental dysfunctions. Chiropractors have also used ICD-9 code 839 (other, multiple, and ill-defined dislocations) to code for subluxations. Use of this code may overlap with a dislocation.

In the absence of a vertebral fracture or dislocation, spinal manipulation under anesthesia is considered investigational, regardless of whether it is administered by a physician (i.e., MD or osteopath), chiropractor, physical therapist, or other health provider.

As noted in the Policy Guidelines, CPT code 22505 should only be used when general anesthesia is administered. Therefore, plans may want to consider reviewing claims for 22505 to ensure that this code is being used appropriately.

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. A search of the published medical literature did not identify any controlled clinical trials. Several case series were identified, which included patients with cervical, thoracic, and lumbar back pain, treated according to varying protocols. In the largest case series, West and colleagues reported on 177 patients with back pain who had failed prior therapy. The patients were treated with 3 sequential manipulations under intravenous sedation, followed by 4 to 6 weeks of further chiropractic spinal manipulation. (1) At the 6-month follow-up, there was a 60% improvement in VAS scores. However, this uncontrolled study cannot isolate the contribution of the manipulation under anesthesia; 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 evaluated the efficacy of manipulation under anesthesia using a self-reported pain questionnaire in a convenience sample of those undergoing spinal manipulation compared to conventional chiropractic treatment. (2) The pain scales decreased by 50% in those treated with MUA compared to a 26% decrease in those receiving conventional treatment. The lack of a true control group limits interpretation of this study. Other small case series focused on the use of manipulation in conjunction with corticosteroid injections. (3, 4) Similarly, this literature does not permit scientific interpretation.

Chiropractic Guidelines

Chiropractic guidelines, referred to as the Mercy Center Consensus Conference, were first issued in 1993 and reaffirmed in 1999. (5) This guideline development process was sponsored by several organizations —Congress of Chiropractic State Associations, American Chiropractic Association, Canadian Chiropractic Association, International Chiropractic Association, Federation of Chiropractic Licensing Boards, and the Foundation for Chiropractic Education and Research. These guidelines gave manipulation under anesthesia an "equivocal" rating, defined as a technology in which "current knowledge exists to support a given indication in a specified patient population, though value can neither be confirmed nor denied."

2004-6 Update

A literature search was performed for the period of 2003 through December 2005. No additional published studies were identified; therefore, the policy statement is unchanged.

2007-8 Update
A search of the MEDLINE database for the period of January 2006 to December 2007 did not identify any new studies of this procedure. The policy statement is unchanged.

References:

1. 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.
2. Palmieri NF, Smoyak S. Chronic low back pain: A study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25:E8-17.
3. Aspegren DD, Wright RE, Hemler DE. Manipulation under epidural anesthesia with corticosteroid injection: two case reports. J Manipulative Physiol Ther 1997; 20(9):618-21.
4. Ben-David B, Raboy M. Manipulation under anesthesia combined with epidural steroid injection. J Manipulative Physiol Ther 1994; 17(9):605-9.
5. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, Burlingame, CA, January 25-30, 1992. Haldeman S, Chapman-Smith D, Petersen DM (eds), Gaithersburg, MD: Aspen Publishers, 1993.

Manipulation Under Anesthesia, Spine
Spinal Manipulation Under Anesthesia