Archived Policies - Therapy


Manipulation Under Anesthesia

Number:THE803.016

Effective Date:09-01-2016

End Date:11-30-2017

Coverage:

Spinal manipulation under any kind of anesthesia, with or without manipulation of other joints (e.g., hip joint), is considered experimental, investigational and/or unproven for treatment of:

1. Chronic spinal pain (cranial, cervical, thoracic, lumbar), and/or

2. Chronic sacroiliac and pelvic pain.

Manipulation under anesthesia involving multiple body joints is considered experimental, investigational and/or unproven for treatment of chronic pain.

Spinal manipulation and manipulation of other joints under anesthesia involving serial (multiple) treatment sessions is considered experimental, investigational and/or unproven.

NOTE: 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.

Description:

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).

Background

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. 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 (facet) and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia) and after epidural injection of corticosteroid and local anesthetic (manipulation postepidural injection). 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.

Rationale:

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 randomized, controlled trial (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) Thirty-eight 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. The 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 (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. 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 manipulations 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.

Summary

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 experimental, investigational and/or unproven.

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:

1. 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

2. Is so severe that muscle relaxant medication, anti-inflammatory medication or analgesic medications are of little benefit, and/or

3. Results in biomechanical impairment which may be alleviated with use of the procedure.

Contract:

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.

Coding:

For closed treatment of vertebral fractures or dislocations, see CPT code 22315.

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

00640, 21073, 22505, 24300, 25259, 26340, 27275, 27570, 27860

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Dagenais S, Mayer J, Wooley JR, et al. Evidence-informed management of chronic low back pain with medicineassisted manipulation. Spine J. 2008; 8(1):142-149.

2. Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013; 21(1):14. PMID 23672974

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. National Academy of Manipulation Under Anesthesia Physicians. Purpose statement and protocols and standards. 2012. <http://drcremata.com>. Accessed November 14, 2014.

11. 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

12. 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.

13. Manipulation Under Anesthesia. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (December 2014) Therapy 8.01.40.

Policy History:

DateReason
9/1/2016 Reviewed. No changes.
6/15/2015 Document updated with literature review. Coverage unchanged.
7/1/2014 Reviewed. No changes.
1/15/2013 Document updated with literature review. Document completely revised and title changed. The following Coverage change(s) were made: 1) Joints other than the spine, and MUA over multiple sessions or for multiple joints are considered experimental, investigational and unproven; 3) Detail was added describing spinal manipulation procedures.
6/1/2008 Policy reviewed without literature review; new review date only.
4/1/2007 Revised/updated entire document
1/1/2004 Revised/updated entire document
2/1/1996 New medical document

Archived Document(s):

Title:Effective Date:End Date:
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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