D7830 — Tmj manipulation under anest
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
- Surgical procedures areconsideredmedically necessaryfor the treatment of temporomandibular disorderswhen the following criteria are met (AandB):
- Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by the following:Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);andFor individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
- Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);and
- For individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
4 Active Policies
UHC-POL-manipulation-under-anesthesia — Manipulation Under Anesthesia
ANTHEM-GL-A051149 — CPT
UMR-POL-UMR-manipulation-under-anesthesia — Manipulation Under Anesthesia
SUREST-POL-SUREST-manipulation-under-anesthesia — Manipulation Under Anesthesia
Related Codes
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