|MP 8.01.40||Manipulation Under Anesthesia|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/12:2014
|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 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 (eg, 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 to 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 to 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) and after epidural injection of corticosteroid and local anesthetic (manipulation postepidural injection).(1) 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 US Food and Drug Administration.
Spinal manipulation (and manipulation of other joints, eg, 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 review was performed through November 10, 2014.
Assessment of efficacy for therapeutic interventions involves a determination of whether the intervention improves health outcomes. The optimal study design for a therapeutic intervention is a randomized controlled trial (RCT) that includes clinically relevant measures of health outcomes. Intermediate outcome measures, also known as surrogate outcome measures, may also be adequate if there is an established link between the intermediate outcome and true health outcomes. Nonrandomized comparative studies and uncontrolled studies can sometimes provide useful information on health outcomes, but are prone to biases such as noncomparability of treatment groups, the placebo effect, and variable natural history of the condition.
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) or medicine-assisted manipulation (MAM) 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 RCT identified was published in 1971 when the techniques for spinal manipulation were different from those used at the present time.(1)
No high-quality RCTs have been identified. A 2013 comprehensive review of the literature describes studies by Kohlbeck et al and Palmieri and Smoyak (described next) as being the best evidence available for MAM/MUA of the spine.(2) Kohlbeck et al 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 on a 100-point scale, 4.4 points; 95% confidence interval [CI], -2.2 to 11.0). This difference attenuated at 1 year (adjusted mean difference, 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 to 13.6) and at 1 year (OR=1.9; 95% CI, 0.6 to 6.5).(3)
In 2014, Peterson et al reported a prospective study of 30 patients with chronic pain (17 low back, 13 neck) who underwent a single MUA session with follow-up at 2 and 4 weeks.(4) The primary outcome measure was the Patient’s Global Impression of Change (PGIC). At 2 weeks, 52% of the patients reported clinically relevant improvement (better or much better) with 45.5% improved at 4 weeks. There was a statistically significant reduction in numeric rating scale (NRS) scores at 4 weeks (p=0.01) from a mean score of 4.0 at 1 day before MUA to 3.5 at 2 weeks post-MUA. Bournemouth Questionnaire (BQ) scores improved from 24.17 to 20.38 at 2 (p=0.008) and 19.45 at 4 weeks (p=0.001). This study is limited by the lack of a sham group to control for a potential placebo effect. In addition, the clinical significance of the improvement in NRS and BQ scores is questioned.
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.(5) Thirtyeight patients with low back pain received MUA and 49 received traditional chiropractic treatment. A numeric pain scale and Roland-Morris Disability Questionnaire (RMDQ) 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; RMDQ 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.
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.(6) Patients underwent 3 sequential manipulations with intravenous sedation followed by 4 to 6 weeks of spinal manipulation and therapeutic modalities; all had 6 months of follow-up. On average, visual analog scale ratings improved by 62% in patients with cervical pain and 60% in patients with lumbar pain. Dougherty et al retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation postepidural injection. 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.(7)
The 1 study of manipulation under joint anesthesia/analgesia (MUJA) found in the literature search had only 4 subjects.(8) 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.”(9)
Searches of the literature using the MEDLINE® database did not find any additional published studies on spinal MUA involving serial sessions or on MUA of multiple joints.
Clinical Input Received From Physician Specialty Societies and Academic Medical Centers
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.
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. Input from the 7 reviewers agreed that MUA for chronic spinal and pelvic pain is investigational.
Summary of Evidence
Scientific evidence regarding spinal manipulation under anesthesia (MUA), 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
In 2012, the American Association of Manipulation Under Anesthesia Providers published guidelines for protocols and standards for MUA, including determining the necessity and frequency of MUA.(10) This was followed in 2014 by a consensus-based guidelines document for the practice and performance of MUA.(11) The guidelines include patient selection criteria, establishing medical necessity, frequency and follow-up procedures, parameters for determining MUA progress, general post MUA therapy, and safety. The guidelines recommend 3 consecutive days of treatment, based on the rationale that serial procedures allow a gentler yet effective treatment plan with better control of biomechanical force. The guidelines also recommend follow-up therapy without anesthesia over 8 weeks after MUA that includes all fibrosis release and manipulative procedures performed during the MUA procedure to help prevent re-adhesion.
The American Academy of Osteopathy (AAO) published a consensus statement in 2005 on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation.(12) AAO states that MUA may be appropriate in cases of restrictions and abnormalities of function that include recurrent muscle spasm, range-of-motion restrictions, persistent pain secondary to injury, and/or repetitive motion trauma and is, in general, limited to patients who have somatic dysfunction which:
- has failed to respond to conservative treatment in the office or hospital that has included the use of osteopathic manipulative therapy, physical therapy and medication, and/or
- is so severe that muscle relaxant medication, anti-inflammatory medication or analgesic medications are of little benefit, and/or
- results in biomechanical impairment which may be alleviated with use of the procedure.
U.S. Preventive Services Task Force Recommendations
The U.S. Preventive Services Task Force has not addressed MUA.
Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.
- 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):142-149.
- Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013;21(1):14. PMID 23672974
- 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):245-252.
- 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. Jul-Aug 2014;37(6):377-382. PMID 24998720
- 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.
- 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.
- 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):449-456.
- 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):537-546.
- 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):127-129.
- National Academy of Manipulation Under Anesthesia Physicians. Purpose statement and protocols andstandards. 2012; http://drcremata.com/research/62-american-association-of-manipulation-under-anesthesiaproviders.
Accessed November 14, 2014.
- Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014;22(1):7. PMID 24490957
- American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. American Academy of Osteopathy Journal. 2005;15(2):26-27.
See Policy Guidelines
Investigational for all diagnoses
|ICD-10-CM (effective 10/1/15)||Investigational for all relevant diagnoses|
|M47.011-M47.9||Spondylosis code range|
|M54.00 –M54.9||Dorsalgia code range|
|ICD-10-PCS (effective 10/1/15)||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|
|12/12/13||Replace policy||Policy updated with literature search through November 11, 2013; references 2 and 9 added; policy statement unchanged|
|12/11/14||Replace policy||Policy updated with literature review through November 10, 2014; references 4 and 11 added; policy statement unchanged|