BlueCross and BlueShield of Montana Medical Policy/Codes
Manipulation Under Anesthesia
Chapter: Therapies
Current Effective Date: April 18, 2013
Original Effective Date: April 18, 2013
Publish Date: January 18, 2013
Description

Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation).

Background

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft tissue adhesions with less force than would be required to overcome patient resistance or apprehension. MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to treat (reduce) fractures (e.g., vertebral, long bones) and dislocations.

MUA has been proposed as a treatment modality for acute and chronic pain conditions, particularly of the spinal region, when standard care, including manipulation, and other conservative measures have been unsuccessful. MUA of the spine has been used in various forms since the 1930s. Complications from general anesthesia and forceful long-lever, high-amplitude nonspecific manipulation procedures resulted in decreased use of the procedure in favor of other therapies. MUA was modified and revived in the 1990s. This revival is attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.

MUA of the spine is described as follows: after sedation is achieved, a series of mobilization, stretching, and traction procedures to the spine and lower extremities is performed and may include passive stretching of the gluteal and hamstring muscles with straight-leg raise, hip capsule stretching and mobilization, lumbosacral traction, and stretching of the lateral abdominal and paraspinal muscles. After the stretching and traction procedures, spinal manipulative therapy (SMT) is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand, while the upper torso and lower extremities are stabilized. SMT may also be applied to the thoracolumbar or cervical area if considered necessary to address the low back pain. The MUA takes 15–20 minutes, and after recovery from anesthesia, the patient is discharged with instructions to remain active and use heat or ice for short-term analgesic control. Some practitioners recommend performing the procedure on 3 or more consecutive days for best results. Care after MUA may include 4–8 weeks of active rehabilitation with manual therapy, including SMT and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia [MUJA]) and after epidural injection of corticosteroid and local anesthetic (manipulation postepidural injection [MUESI]). (1) Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions.

Policy

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers spinal manipulation under any kind of anesthesia, with or without manipulation of other joints (e.g., hip joint), experimental, investigational and unproven for treatment of:

  1. Chronic spinal pain (cranial, cervical, thoracic, lumbar), and/or
  2. Chronic sacroiliac and pelvic pain.

Manipulation under anesthesia involving multiple body joints is considered experimental, investigational and unproven for treatment of chronic pain.

Spinal manipulation and manipulation of other joints under anesthesia involving serial (multiple) treatment sessions is considered experimental, investigational and unproven.

NOTE: This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

Federal Mandate

Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.

Policy Guidelines

For closed treatment of vertebral fractures or dislocations, see CPT code 22315.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. BCBSMT recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

Randomized, placebo-controlled trials are considered particularly important when assessing treatment of low back pain, to control not only for the expected placebo effect but to also control for the variable natural history of low back pain, which may resolve with conservative treatment alone. Dagenais et al., in a 2008 comprehensive review of the history of manipulation under anesthesia (MUA) and the published experimental literature noted that there is no research to confirm theories about a mechanism of action for these procedures and that the only randomized, controlled trial identified was published in 1971 when the techniques for spinal manipulation were different from those used at the present time. (1)

West et al. reported on a series of 177 patients with pain arising from the cranial, cervical, thoracic, and lumbar spine, as well as the sacroiliac and pelvic regions who had failed conservative and surgical treatment. (2) Patients underwent 3 sequential manipulations with intravenous (IV) sedation followed by 4–6 weeks of spinal manipulation and therapeutic modalities; all had 6 months of follow-up. On average, visual analogue scale (VAS) ratings improved by 62% in patients with cervical pain and 60% in patients with lumbar pain. Kohlbeck and colleagues carried out a prospective cohort study of 68 patients with chronic low back pain. (3) All patients received an initial 4- to 6-week trial of spinal manipulation therapy (SMT), after which 42 patients received supplemental intervention with MUA and the remaining 26 patients continued with SMT. Low back pain and disability measures favored the MUA group over the SMT-only group at 3 months (adjusted mean difference of 4.4 points on a 100-point scale, 95% confidence interval [CI]: -2.2 to 11.0). This difference attenuated at 1 year (adjusted mean difference of 0.3 points, 95% CI: -8.6 to 9.2). The relative odds of experiencing a 10-point improvement in pain and disability favored the MUA group at 3 months (odds ratio [OR]: 4.1, 95% CI: 1.3-13.6) and at 1 year (OR: 1.9, 95% CI: 0.6-6.5. (3) Palmieri and Smoyak evaluated the efficacy of using self-reported questionnaires to study MUA using a convenience sample of 87 subjects in 2 ambulatory surgery centers and 2 chiropractic clinics. (4) Thirty-eight patients with low back pain received MUA and 49 received traditional chiropractic treatment. A numeric pain scale and Roland Morris Questionnaire were administered at baseline, after the procedure, and 4 weeks later. Average pain scale scores in the MUA group decreased by 50% versus 26% in the traditional treatment group; Roland Morris Questionnaire scores decreased by 51% and 38%, respectively. The authors concluded that the study supports the need for large-scale studies on MUA and that the assessments are easily administered and dependable.

Dougherty et al. retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation postepidural injection (MUESI). After epidural injection of lidocaine (guided fluoroscopically or with computed tomography), methylprednisolone acetate flexion distraction mobilization and then high-velocity, low-amplitude spinal manipulation were delivered to the affected spinal regions. Outcome criteria were empirically defined as significant improvement, temporary improvement, or no change. Among lumbar spine patients, 22 (37%) noted significant improvement, 25 (42%) reported temporary improvement, and 13 (22%) no change. Patients receiving cervical epidural injection reported the following: 10 (50%) significant improvement, 6 (30%) temporary relief, and 4 (20%), no change. The authors noted that this is the first report of the use of spinal manipulation postepidural injection in the cervical spine. (5)

The 1 study of manipulation under joint anesthesia/analgesia (MUJA) found in the literature search had only 4 subjects. (6) Michaelsen noted in a paper published in 2000 that MUJA should be viewed with “guarded optimism because its success is based solely on anecdotal experience”. (7)

Practice Guidelines and Position Statements

The National Academy of Manipulation Under Anesthesia Physicians published guidelines for determining the necessity and frequency of MUA in 2002. (Available online at: http://www.fcghealth.com )

Summary

Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series and nonrandomized comparative studies. Evidence regarding the efficacy of MUA over several sessions or for multiple joints is also lacking. Evidence is insufficient to determine whether MUA improves health outcomes; thus, it is considered experimental, investigational and unproven.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes
Investigational for all diagnoses.  80.40, 80.41, 80.42, 80.43, 80.44, 80.45, 80.46, 80.47, 80.48, 80.49
ICD-10 Codes
Investigational for all relevant diagnoses.  M47.011-M47.9, M54.00-M54.9, ORN0XZZ, ORN1XZZ, ORN3XZZ, ORN4XZZ, ORN5XZZ, ORN6XZZ, ORN9XZZ, ORNAXZZ, ORNBXZZ, OSN0XZZ, OSN2XZZ, OSN3XZZ, OSN4XZZ, OSN5XZZ, OSN6XZZ 
Procedural Codes: 22505, 00640
References
  1. Dagenais S, Mayer J, Wooley JR et al. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J 2008; 8(1):142-9.
  2. West DT, Mathews RS, Miller MR et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999; 22(5):299-308.
  3. Kohlbeck FJ, Haldeman S, Hurwitz EL et al. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther 2005; 28(4):245-52.
  4. Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25(8):E8-E17.
  5. Dougherty P, Bajwa S, Burke J et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther 2004; 27(7):449-56.
  6. Dreyfuss P, Michaelsen M, Horne M. MUJA: manipulation under joint anesthesia/analgesia: a treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther 1995; 18(8):537-46.
  7. Michaelsen MR. Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin. J Manipulative Physiol Ther 2000; 23(2):127-9.
  8. Manipulation Under Anesthesia. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (October 2011) Therapy 8.01.40.
History
January 2013 

New 2013 BCBSMT medical policy.  Considered investigational. 

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Manipulation Under Anesthesia