28665
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
1.92
Facility
$119.91
Non-Facility
$154.98
Documentation Required
- Documentation of failure of conservative medical management appropriate to the indication (examples provided in policy): for adhesive capsulitis - medications with or without articular injections, home exercise programs and physical therapy/standard chiropractic treatment.
- For post-traumatic/postoperative arthrofibrosis of the knee: documentation that range of motion is <90° following surgery or trauma despite physical therapy.
- For chronic contracture: documentation of failure of conservative management including range of motion exercise programs and physical therapy/standard chiropractic treatment.
- Clinical documentation supporting the diagnosis (e.g., operative notes, imaging, physical exam findings) for fractures or dislocations when MUA is performed as part of fracture/dislocation reduction or surgical repair (MUA considered incidental to base procedure in this context).
Key Coverage Criteria
- A single treatment of manipulation under anesthesia (MUA) is considered medically necessary for adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy/standard chiropractic treatment (CPT code 23700).
- A single treatment of MUA is considered medically necessary for post-traumatic or postoperative arthrofibrosis of the knee (e.g., total knee replacement, anterior cruciate ligament repair) when there is failure of conservative medical management, including exercise and physical therapy/standard chiropractic treatment (CPT code 27570).
- A single treatment of MUA is considered medically necessary for reduction of a displaced fracture (e.g., vertebral, long bones) (e.g., CPT code 22505).
- A single treatment of MUA is considered medically necessary for reduction of acute/traumatic dislocation (e.g., vertebral, perched cervical facet) (e.g., CPT code 22505).
- A single treatment of MUA is considered medically necessary for chronic contracture of upper or lower extremity joint (e.g., fixed contracture from a neuromuscular condition) when there is failure of conservative medical management including range of motion exercise programs and physical therapy/standard chiropractic treatment.
1 Active Policy
CIGNA-0276 — Manipulation Under Anesthesia - (0276)
Related Codes
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