26340
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
2.73
Facility
$365.41
Non-Facility
$365.41
Documentation Required
- 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."
Key Coverage Criteria
- 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.
- Manipulation under anesthesia, shoulder joint (CPT 23700) for adhesive capsulitis when selection criteria are met (see Appendix).
- Manipulation of temporomandibular joint(s) requiring anesthesia (CPT 21073) for temporomandibular joint disorders when selection criteria/diagnosis documented.
- ICD-10 codes listed as covered if selection criteria are met for knee arthrofibrosis: M24.661 - M24.669 (Ankylosis of joint, knee [arthrofibrosis following total knee arthroplasty]), Z96.651 - Z96.659 (Presence of artificial knee joint [arthrofibrosis following total knee arthroplasty]), and related fracture codes (e.g., S72.401+ - S72.499+, S79.101+ - S79.199+, S82.* ranges, S83.*, S89.* ranges) as listed in the policy.
- ICD-10 codes listed as covered if selection criteria are met for frozen shoulder: M75.00 - M75.02 (Adhesive capsulitis of shoulder) [only if X-rays do not show bone pathology that can explain the loss of motion].
12 Active Policies
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 — Manipulation Under Anesthesia - (0276)
AETNA-CPB-0204 — Manipulation Under General Anesthesia
Related Codes
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