Archived Policies - Therapy

Spinal Manipulation under Anesthesia


Effective Date:01-23-2004

End Date:03-31-2007


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


In the appendicular skeleton, manipulation of the patient under anesthesia may be performed as a treatment of arthrofibrosis, particularly of the shoulder (i.e. frozen shoulder) or knee.  In the spine, MUA 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 of dislocation, MUA performed either with the patient sedated or under general anesthesia is intended to overcome the conscious patient’s protective reflex mechanism, which may have limited 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.


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. At 6-month follow-up, there was a 60% improvement in their Visual Analog Scale (VAS) scores. However, this uncontrolled study cannot isolate the contribution of the manipulation under anesthesia compared to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition. Other small case series focused on the use of manipulation in conjunction with corticosteroid injections. Similarly, this literature does not permit scientific interpretation.


Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.



Medicare Coverage:



West DT, Mathews RS, Miller MR et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics 1999; 22(5):299-308.

Aspegren DD, Wright RE, Hemler DE. Manipulation under epidural anesthesia with corticosteroid injection: two case reports. Journal of Manipulative and Physiological Therapeutics 1997; 20(9):618-21.

Ben-David B, Raboy M. Manipulation under anesthesia combined with epidural steroid injection. Journal of Manipulative and Physiological Therapeutics 1994; 17:605-9.

Policy History:

Archived Document(s):

Title:Effective Date:End Date:
Manipulation Under Anesthesia08-01-201907-14-2020
Manipulation Under Anesthesia06-15-201807-31-2019
Manipulation Under Anesthesia12-01-201706-14-2018
Manipulation Under Anesthesia09-01-201611-30-2017
Manipulation Under Anesthesia06-15-201508-31-2016
Manipulation Under Anesthesia07-01-201406-14-2015
Manipulation Under Anesthesia01-15-201306-30-2014
Spinal Manipulation under Anesthesia06-01-200801-14-2013
Spinal Manipulation under Anesthesia04-01-200705-31-2008
Spinal Manipulation under Anesthesia01-23-200403-31-2007
Manipulation of Spine Requiring Anesthesia, Any Region05-01-199601-22-2004
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