Payer PolicyActive
CMM-310: Manipulation Under Anesthesia
EVICORE-MSK_ADVANCED-B0C930E0
EviCore by Evernorth
Effective: August 1, 2022
Updated: January 13, 2026
created · Dec 5, 2025
Policy Summary
Covered only as a closed, emergent treatment for traumatically induced vertebral fracture or dislocation to mitigate potential neurological compromise (not covered for non‑traumatic, elective, or routine spinal conditions). Key requirements: a qualified physician must have considered open reduction first, the procedure must be done under sedation/general anesthesia and paired with an active rehabilitation/ home exercise program, and documentation must include imaging, emergent indication, physician consultation, anesthesia record, and PT/rehab plan.
Coverage Criteria Preview
Key requirements from the full policy
"The use of manipulation of the spine when the patient is either sedated or under general anesthesia may be considered medically necessary as a closed treatment of traumatically induced vertebral fr..."
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