Archived Policies - Therapy
Manipulation Under Anesthesia
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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.
Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually with general anesthesia or moderate sedation).
Manipulation Under Anesthesia
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 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 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 spine, when standard care, including manipulation, and other conservative measures have failed. 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 led to decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival has been 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, a series of mobilization, stretching, and traction procedures to the spine and lower extremities are 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 is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand, while the upper torso and lower extremities are stabilized. Spinal manipulative therapy may also be applied to the thoracolumbar or cervical area when necessary to address low back pain.
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 spinal manipulative therapy 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 MUA has also been combined with other joint manipulation during multiple sessions. Together, these therapies may be referred to as medicine-assisted manipulation.
Manipulative procedures are not subject to regulation by the U.S. Food and Drug Administration.
The medical policy was created in 1996 and has been updated regularly with searches of the MEDLINE database. The most recent literature updatewas performed through February 18,2019.
Medical policies assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes arethe lengthof life, quality of life(QOL), and ability to function-including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managingthe course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.
To assess whether the evidence is sufficient todraw conclusions aboutthe net health outcome of technology, two domainsare examined: the relevance,and quality and credibility.To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial(RCT)is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate.RCTsare rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.
Manipulation Under Anesthesia (MUA)
Clinical Context and Therapy Purpose
The purpose of MUA is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as conservative management, in patients with chronic spinal, sacroiliac, or pelvic pain.
The question addressed in this medical policy is: Does MUA improve the net health outcome in individuals with chronic spinal, sacroiliac, or pelvic pain?
The following PICOTS were used to select literature to inform this policy.
The relevant population of interest are individuals with chronic spinal, sacroiliac, or pelvic pain.
The therapy being considered is MUA.
Comparators of interest include conservative management.
Conservative management includes steroid regimens, blood pressure medication, muscle relaxers, and physical therapy, and is managed by physical therapists and primary care providers in an outpatient clinical setting.
The general outcomes of interest are symptoms, functional outcomes, QOL, and treatment-related morbidity.
The most significant outcome of interest was improvement in QOL. At 2 weeks, 52% of the patients reported clinically relevant improvement (better or much better), with 45.5% improved at 4 weeks. There was also a statistically significant reduction in numeric rating scale scores for pain at four weeks after the procedure.
Table 1. Outcomes of Interest for Individualswith Chronic Spinal, Sacroiliac, or Pelvic Pain
Measures of range of motion, observation of mobility post-op
Quality of life
Measures of pain, measures of anxiety or depression
The existing literature evaluating MUA as a treatment for chronic spinal, sacroiliac, or pelvic pain has varying lengths of follow-up, ranging from two weeks to six months. While studies described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, six months of follow-up is considered necessary to demonstrate efficacy.
Patients with chronic spinal, sacroiliac, or pelvic pain are actively managed by orthopedic surgeons and primary care providers in an outpatient clinical setting.
Study Selection Criteria
Methodologically credible studies were selected using the following principles:
• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;
• Studies with duplicative or overlapping populations were excluded.
Dagenais et al. (2008) conducted a comprehensive review of the history of MUA or medicine-assisted manipulation and the published experimental literature. (1) They noted that there was 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 differed from those used presently.
Nonrandomized Comparative Studies
No high-qualityRCTshavebeen identified.A comprehensive review of the literature by Digiorgi (2013) (2) described studies by Kohlbeck et al. (2005) (3) and Palmieri and Smoyak (2002) (4) as being the best evidence available for medicine-assisted manipulation and MUA of the spine.
Kohlbeck et al. (2005) reported on a nonrandomized comparative study that included 68 patients with chronic low back pain. (3) All patients received an initial 4- to 6-week trial of spinal manipulation therapy, after which 42 patients received supplemental intervention with MUA and 26 continued with spinal manipulative therapy. Low back pain and disability measures favored the MUA group over the spinal manipulative therapy-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).
Palmieri and Smoyak (2002) evaluated the efficacy of self-reported questionnaires to study MUA in a convenience sample of 87 subjects from 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 the Roland-Morris Disability Questionnaire were administered at baseline, after the procedure, and 4 weeks later. Average pain scale scores in the MUA group decreased by 50% and by 26% in the traditional treatment group; Roland-Morris Disability Questionnaire scores decreased by 51% and 38%, respectively. Although the authors concluded that the study supported the need for large-scale studies on MUA and that the assessments are easily administered and dependable, no large-scale studies comparing MUA with traditional chiropractic treatment have been identified.
Peterson et al. (2014) reported on 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. (5) The primary outcome measure was the Patient’s Global Impression of Change. 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 scores at 4 weeks (p=0.01), from a mean baseline score of 4.0 to 3.5 at 2 weeks post-MUA. Bournemouth Questionnaire scores improved from 24.17 to 20.38 at 2 weeks (p=0.008) and to 19.45 at 4 weeks (p=0.001). This study lacked a sham group to control for a potential placebo effect. Also, the clinical significance of improved numeric rating scale and Bournemouth Questionnaire scores is unclear.
West et al. (1999) 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 by 60% in patients with lumbar pain. Dougherty et al. (2004) retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation postepidural injection. (7) 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. Among patients receiving cervical epidural injection, 10 (50%) had significant improvement, 6 (30%) had temporary relief, and 4 (20%) had no change.
The only study (1995) of manipulation under joint anesthesia or analgesia found had 4 subjects; it was reported by Dreyfuss et al. (1995). (8) Later, Michaelsen (2000) noted that joint-related MUA should be viewed with “guarded optimism because its success is based solely on anecdotal experience.” (9)
Table 2. Summary of Characteristics of Key Observational Comparative Studies of Manipulation under Anesthesia
Peterson (2014) (5)
Patients (n=30) with chronic pain who underwent single MUA session
MUA for those with low back pain (n=17)
MUA for those with neck pain (n=13)
2 and 4 weeks
West (1999) (6)
July 1995-Feb 1997
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
Patients underwent 3 sequential manipulations with intravenous sedation followed by 4 to 6 weeks of spinal manipulation and therapeutic modalities
Dougherty (2004) (7)
Nov 1996-Nov 2000
20 cervical and 60 lumbar radiculopathypatients who underwent spinal manipulation after epidural injection. The patients ranged in age from 21-76 years old with an average age of 43 F 8.9 years.
Forty-three percent of the patients were female patients and 57% were male patients.
Following epidural injection of lidocaine (guidedfluoro-scopicallyor with computed tomography),methyl-prednisolone acetate flexion distraction mobilization and high-velocity, low-amplitude spinal manipulationwere deliveredto the affected spinal regions
CH: Switzerland; Ctry: country; MUA: manipulation under anesthesia; NR: not reported; NA: not available; Pro: prospective; Retro: retrospective; US: United States.
Table 3. Summary of Results of Key Observational Comparative Studies of Manipulation under Anesthesia
Improvement as Reported by Participant
Bournemouth Questionnaire score
Patient’s Global Impression of Change
Peterson (2014) (5)
“better or much better” reported at 2 weeks post
“better or much better” reported at 4 weeks post
West (1999) (6)
% of cervical patients with improvement
% of lumbar patients with improvement
Dougherty (2004) (7)
Lumbar spine patients
% noting significant improvement
% noting temporary improvement
% noting no improvement
Patients receiving cervical epidural injection
% noting significant improvement
% noting temporary improvement
% noting no improvement
Summary of Evidence
For individuals who have chronic spinal, sacroiliac, or pelvic pain who receive manipulation under anesthesia (MUA), the evidence includes case series and nonrandomized comparative studies. The relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Scientific evidence on spinal MUA, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is very limited. No randomized controlled trials have been identified. Evidence on the efficacy of MUA over several sessions or for multiple joints is also lacking. The evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines and Position Statements
American Association of Manipulation Under Anesthesia Providers
The American Association of Manipulation Under Anesthesia Providers (2014) published consensus-based guidelines for the practice and performance of MUA. (10) The guidelines included patient selection criteria, establishing medical necessity, frequency and follow-up procedures, parameters for determining MUA progress, general post-MUA therapy, and safety. The guidelines recommended 3 consecutive days of treatment, based on the premise that serial procedures allow a gentler yet effective treatment plan with better control of biomechanical force. The guidelines also recommended 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.
American Academy of Osteopathy
The American Academy of Osteopathy (2005) published a consensus statement on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. (11) The Academy stated that MUA “may be appropriate in cases of restrictions and abnormalities of function. These include recurrent muscle spasm, range of motion restrictions, persistent pain secondary to injury and/or repetitive motion trauma…. In general, MUA is 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 OMT [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.”
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in March 2019 did not identify any ongoing or unpublished trials that would likely influence this policy.
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.
For closed treatment of vertebral fractures or dislocations, see CPT code 22315.
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.
The following codes may be applicable to this Medical policy and may not be all inclusive.
00640, 21073, 22505, 23700, 24300, 25259, 26340, 27275, 27570, 27860
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
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>.
1. Dagenais S, Mayer J, Wooley JR, et al. Evidence-informed management of chronic low back pain with medicine- assisted manipulation. Spine J. Jan-Feb 2008; 8(1):142-149. PMID 18164462
2. Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. May 14, 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. May 2005; 28(4):245-252. PMID 15883577
4. Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther. Oct 2002; 25(8):E8-E17. PMID 12381983
5. 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
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. Jun 1999; 22(5):299-308. PMID 10395432
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. Sep 2004; 27(7):449-456. PMID 15389176
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. Oct 1995; 18(8):537-546. PMID 8583177
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. Feb 2000; 23(2):127-129. PMID 10714542
10. Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. Feb 03, 2014; 22(1):7. PMID 24490957
11. American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. AAO J. Jun 2005; 15(2):26-27.
12. Manipulation Under Anesthesia. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (May 2019) Therapy 8.01.40.
|8/1/2019||Document updated with literature review. Coverage unchanged. No new references added.|
|6/15/2018||Reviewed. No changes.|
|12/1/2017||Document updated with literature review. Coverage unchanged.|
|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|
|Title:||Effective Date:||End Date:|
|Manipulation Under Anesthesia||08-01-2019||07-14-2020|
|Manipulation Under Anesthesia||06-15-2018||07-31-2019|
|Manipulation Under Anesthesia||12-01-2017||06-14-2018|
|Manipulation Under Anesthesia||09-01-2016||11-30-2017|
|Manipulation Under Anesthesia||06-15-2015||08-31-2016|
|Manipulation Under Anesthesia||07-01-2014||06-14-2015|
|Manipulation Under Anesthesia||01-15-2013||06-30-2014|
|Spinal Manipulation under Anesthesia||06-01-2008||01-14-2013|
|Spinal Manipulation under Anesthesia||04-01-2007||05-31-2008|
|Spinal Manipulation under Anesthesia||01-23-2004||03-31-2007|
|Manipulation of Spine Requiring Anesthesia, Any Region||05-01-1996||01-22-2004|