|MP 8.01.40||Manipulation Under Anesthesia|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/10:2012
|Return to Medical Policy Index|
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (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. Manipulation under anesthesia (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 treat (reduce) fractures (e.g., vertebral, long bones) and dislocations.
MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spinal region, 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 resulted in 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 is achieved, a series of mobilization, stretching, and traction procedures to the spine and lower extremities is 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 if considered necessary to address the low back pain. The 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 and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia [MUJA]) and after epidural injection of corticosteroid and local anesthetic (manipulation postepidural injection [MUESI]). (1) Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions.
Spinal 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.
This policy 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.
CPT code 22505 specifically identifies manipulation of the spine under anesthesia:
No applicable information
The policy was created with an initial literature search in 2002 and updated periodically using the MEDLINE database. The most recent update with literature search covers the period of September 2011 through August 2012. Following is a summary of the literature.
Randomized, placebo-controlled trials are considered particularly important when assessing treatment of low back pain, to control not only for the expected placebo effect but to also control for the variable natural history of low back pain, which may resolve with conservative treatment alone. Dagenais et al., in a 2008 comprehensive review of the history of manipulation under anesthesia (MUA) and the published experimental literature, noted that there is no research to confirm theories about a mechanism of action for these procedures and that the only randomized, controlled trial identified was published in 1971 when the techniques for spinal manipulation were different from those used at the present time. (1)
West et al. reported on a series of 177 patients with pain arising from the cranial, cervical, thoracic, and lumbar spine, as well as the sacroiliac and pelvic regions who had failed conservative and surgical treatment. (2) Patients underwent 3 sequential manipulations with intravenous (IV) sedation followed by 4–6 weeks of spinal manipulation and therapeutic modalities; all had 6 months of follow-up. On average, visual analogue scale (VAS) ratings improved by 62% in patients with cervical pain and 60% in patients with lumbar pain. Kohlbeck and colleagues carried out a prospective cohort study of 68 patients with chronic low back pain. (3) All patients received an initial 4- to 6-week trial of spinal manipulation therapy (SMT), after which 42 patients received supplemental intervention with MUA and the remaining 26 patients continued with SMT. Low back pain and disability measures favored the MUA group over the SMT-only group at 3 months (adjusted mean difference of 4.4 points on a 100-point scale, 95% confidence interval [CI]: -2.2 to 11.0). This difference attenuated at 1 year (adjusted 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 favored the MUA group at 3 months (odds ratio [OR]: 4.1, 95% CI: 1.3-13.6) and at 1 year (OR: 1.9, 95% CI: 0.6-6.5. (3) Palmieri and Smoyak evaluated the efficacy of using self-reported questionnaires to study MUA using a convenience sample of 87 subjects in 2 ambulatory surgery centers and 2 chiropractic clinics. (4) Thirty-eight patients with low back pain received MUA and 49 received traditional chiropractic treatment. A numeric pain scale and Roland Morris Questionnaire were administered at baseline, after the procedure, and 4 weeks later. Average pain scale scores in the MUA group decreased by 50% versus 26% in the traditional treatment group; Roland Morris Questionnaire scores decreased by 51% and 38%, respectively. The authors concluded that the study supports the need for large-scale studies on MUA and that the assessments are easily administered and dependable.
Dougherty et al. retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation postepidural injection (MUESI). After epidural injection of lidocaine (guided fluoroscopically or with computed tomography), methylprednisolone acetate flexion distraction mobilization and then high-velocity, low-amplitude spinal manipulation were delivered to the affected spinal regions. Outcome criteria were empirically defined as significant improvement, temporary improvement, or no change. Among lumbar spine patients, 22 (37%) noted significant improvement, 25 (42%) reported temporary improvement, and 13 (22%) no change. Patients receiving cervical epidural injection reported the following: 10 (50%) significant improvement, 6 (30%) temporary relief, and 4 (20%), no change. The authors noted that this is the first report of the use of spinal manipulation postepidural injection in the cervical spine. (5)
The one study of manipulation under joint anesthesia/analgesia (MUJA) found in the literature search had only 4 subjects. (6) Michaelsen noted in a paper published in 2000 that MUJA should be viewed with “guarded optimism because its success is based solely on anecdotal experience.” (7)
A search of the literature using the MEDLINE® database through August 2010 did not find any additional published studies on spinal manipulation under anesthesia involving serial sessions or on manipulation under anesthesia of multiple joints.
Clinical Input Received through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received from 2 physician specialty societies and 4 academic medical centers while this policy was under review in 2009. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. Input from the 7 reviewers agreed that manipulation under anesthesia for chronic spinal and pelvic pain is investigational.
Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. Evidence is insufficient to determine whether MUA improves health outcomes; thus, it is considered investigational.
Practice Guidelines and Position Statements
The National Academy of Manipulation Under Anesthesia Physicians published guidelines for determining the necessity and frequency of MUA in 2002. (Available online at: http://www.fcghealth.com/pages/mua_phys_corn_national_namua.htm.)
Medicare National Coverage
Medicare has not published a national coverage decision related to spinal MUA, MUJA, or MUESI.
- Dagenais 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.
- 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.
- Kohlbeck FJ, Haldeman S, Hurwitz EL 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.
- 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.
- Dougherty P, Bajwa S, Burke 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.
- Michaelsen 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.
See Policy Guidelines
Investigational for all diagnoses
|ICD-10-CM (effective 10/1/14)||Investigational for all relevant diagnoses|
|M47.011-M47.9||Spondylosis code range|
|M54.00 –M54.9||Dorsalgia code range|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS codes are only used for inpatient services.|
|ORN0XZZ, ORN1XZZ, ORN3XZZ, ORN4XZZ, ORN5XZZ, ORN6XZZ, ORN9XZZ, ORNAXZZ, ORNBXZZ||Surgical, upper joints, release, external, codes by anatomical location|
|OSN0XZZ, OSN2XZZ, OSN3XZZ, OSN4XZZ, OSN5XZZ, OSN6XZZ||Surgical, lower joints, release, external, codes by anatomical location|
|05/15/02||Add policy to Therapy section||New policy|
|10/9/03||Replace policy||Policy updated; no change in policy statement; additional ICD-9 coding information added|
|03/15/05||Replace policy||Policy updated with literature search; no change in policy statement|
|03/7/06||Replace policy||Policy updated with literature search; no change in policy statement. Policy guidelines section on anesthesia coding updated|
|01/10/08||Replace Policy||Policy updated with literature search; no change in policy statement. Policy no longer scheduled for review.|
|04/24/09||Replace policy||The policy was returned to active review and updated with a literature search. Clinical input was reviewed. Policy was updated extensively and title changed from Spinal Manipulation under Anesthesia. Policy conclusion unchanged; procedure is considered investigational.|
|04/08/10||Replace policy||Policy updated with literature search through February 2010; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through August 2010; title changed to “Manipulation under Anesthesia” to include joints other than the spine; statements added that MUA over multiple sessions or for multiple joints are considered investigational|
|10/04/11||Replace policy||Policy updated with literature search through August 2011; policy statement unchanged|
|10/11/12||Replacy Policy||Policy updated with literature search through August 2012; policy statement unchanged|