Does 22505 require prior authorization?

Yes, 22505 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 22505?

Medicare facility rate: $153.64. Non-facility rate: $153.64. Work RVU: 1.82.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

1.82

Facility

$153.64

Non-Facility

$153.64

For shoulder adhesive capsulitis: medical necessity clinical coverage criteria per InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder (policy text: "For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder.")
Diagnosis documentation supporting 'Arthrofibrosis' of the knee (policy definition provided: "Arthrofibrosis: A complication of injury or trauma where an excessive scar tissue response leads to painful restriction of joint motion, with scar tissue forming within the joint and surrounding soft tissue spaces and persisting despite rehabilitation exercises and stretches.")
Although the policy lists CPT/HCPCS/ICD-10 codes for reference (e.g., CPT codes 27570, 23700, 27275, 27570, HCPCS D7830, ICD-10 codes M24.661, M24.662, M24.669, M24.611, M24.612, M24.619, M75.00, M75.01, M75.02), the policy states: "The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only... Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service."

Manipulation under anesthesia (MUA) is proven and medically necessary for: Knee joint for Arthrofibrosis following total knee arthroplasty, knee surgery, or fracture
Manipulation under anesthesia (MUA) is proven and medically necessary for: Shoulder joint for adhesive capsulitis (frozen shoulder) when certain criteria are met. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Manipulation Under Anesthesia, Shoulder.
NUCCA (National Upper Cervical Chiropractic Association) atlas realignment — pilot randomized, placebo-controlled study reported 'restoration of Atlas alignment was associated with marked and sustained reductions in BP similar to the use of 2-drug combination therapy' (Bakris et al., 2007) — i.e., potential benefit for stage 1 hypertension in a single-center pilot trial.
Chiropractic services are medically necessary when ALL of the following criteria are met: (1) the member has a neuromusculoskeletal disorder; (2) the medical necessity for treatment is clearly documented; and (3) improvement is documented within the initial 2 weeks of chiropractic care.
If improvement is not documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.

AETNA-CPB-0398 — Idiopathic Scoliosis

UHC-POL-manipulation-under-anesthesia — Manipulation Under Anesthesia

UMR-POL-UMR-manipulation-under-anesthesia — Manipulation Under Anesthesia

SUREST-POL-SUREST-manipulation-under-anesthesia — Manipulation Under Anesthesia

CIGNA-0276

Ask Verity about documentation requirements, denial risks, or coverage in your state.