Manipulation of Musculoskeletal System Under Anesthesia (General, Mild Sedation and Local)
DESCRIPTION
Manipulation under anesthesia (MUA) consists of passive movements and stretching of joints performed while the individual receives anesthesia (usually short acting anesthetics or moderate sedation).
Manipulation refers to a variety of manual adjustment techniques and is believed to ease pressure on nerves, break up fibrous scar tissue or restore normal musculoskeletal alignment to relieve pain and improve range of motion. Anesthesia or sedation is used to lessen pain, spasm and the conscious reflex muscle guarding; thereby reducing resistance and apprehension for the individual and enhance the therapeutic effects of the joint manipulation through a full range of motion. Manipulation procedures can be offered under general anesthesia, during mild sedation, or following the injection of anesthetic solutions (i.e. local anesthetic agent) into specific areas of the spine or joints. Typically, MUA is an alternative to conservative treatments that have lasted at least six to eight weeks without relieving pain or promoting a return to normal function.
Spinal manipulation under anesthesia has been used in the treatment of acute and chronic back and neck pain where there has been limited success of prior attempts to manipulate the spine. In MUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical chiropractic/osteopathic adjustment.
MUA has also been used as a treatment for fibroarthrosis following total knee replacement, in refractory cases of adhesive capsulitis (frozen shoulder), in the setting of displaced fractures and complete joint dislocations, and for temporomandibular joint syndrome.
POLICY
Manipulation under anesthesia is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below).
Manipulation under anesthesia for other joints including the wrist, elbow, hand, finger, ankle, and pelvis, in the absence of fracture or complete dislocation, is considered investigational.
Spinal manipulation under anesthesia, (e.g. general anesthesia, joint anesthesia, epidural anesthesia with corticosteroid injections) as a treatment for conditions including, but not limited to chronic spinal pain (e.g. cranial, cervical, thoracic, and lumbar) and chronic sacroiliac and pelvic pain, is considered investigational.
Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions (greater than 1 treatment) is considered investigational.
See also:
MEDICAL APPROPRIATENESS
Manipulation under anesthesia is considered medically appropriate if ANY ONE of the following criteria are met:
Treatment of adhesive capsulitis that has failed at least 3 months of conservative interventions (e.g. physical therapy, patient directed exercise, NSAIDS, and/or steroid injections)
Arthrofibrosis of the knee following total knee arthroplasty, knee surgery, or fracture
Temporomandibular joint disorder
Closed reduction of displaced fracture
Complete joint dislocation
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. A search of the published medical literature did not identify any controlled clinical trials. Several case series were identified, which included individuals with cervical, thoracic and lumbar back pain, treated according to varying protocols.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2010). Manipulation under anesthesia for the treatment of chronic and pelvic pain. (8.01.40). Retrieved December 13, 2010 from BlueWeb. (7 articles and/or guidelines reviewed)
Cremata, E., Collins, S., Clauson, W., Solinger, A., & Roberts, E. (2005) Manipulation under anesthesia: A report of four cases. Journal of Manipulative and Physiological Therapeutics, 28 (7), 526-533. (Level 4 Evidence - Independent)
ECRI Institute. Health Technology Information Service. Evidence Reports. (2003, February). Manipulation under anesthesia for low-back pain. Retrieved December 10, 2010 from ECRI Institute. (66 articles and/or guidelines reviewed)
Kawchuk, G., Haugen, R., Fritz, J. (2009). A true blind for subjects who receive spinal manipulation therapy. Archives of Physical Medicine and Rehabilitation, 90 (2), 366-368. (Level 4 Evidence - Independent)
Manske, R., Prohaska, D. (2008). Diagnosis and management of adhesive capsulitis. Current Reviews of Musculoskeletal Medicine, 1 (3-4), 180-189. (Level 5 Evidence - Independent.)
Mohammed, R., Syed, S., & Ahmed, N. (2009). Manipulation under anesthesia for stiffness following knee arthroplasty. Annals of the Royal College of Surgeons of England, 91 (3), 220-223. (Level 4 Evidence - Independent)
ORIGINAL EFFECTIVE DATE: 8/1/2002
MOST RECENT REVIEW DATE: 5/14/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.