HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-197-014
Topic:
Manipulation Under Anesthesia
Section:
Surgery
Effective Date:
May 30, 2022
Issued Date:
October 9, 2023
Last Revision Date:
August 2023
Annual Review:
August 2023
 
 

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

Policy Position

MUA of the Knee

MUA of the knee may be considered medically necessary when ALL of the following are met:

  • To treat significant arthrofibrosis of the knee resulting from trauma or knee surgery; and
  • After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
  • Is limited to a single treatment session.

MUA of the knee is considered not medically necessary for the following indication:

  • Serial manipulations of the same joint (MUA is limited to a single treatment session).

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the knee not meeting the criteria as indicated in this policy is considered not medically necessary.

27570

 

 

 

 

 

 




MUA of the Shoulder

MUA of the shoulder may be considered medically necessary when ALL of the following are met:

  • To treat capsulitis of the shoulder; and
  • After an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain; and
  • Is limited to a single treatment session.

MUA of the shoulder is considered not medically necessary for the following indication:

  • Serial manipulations of the same joint (MUA is limited to a single treatment session).

 

When MUA is not medically necessary, all associated services, such as anesthesia and facility expenses will also be considered not medically necessary.

MUA of the shoulder not meeting the criteria as indicated in this policy is considered not medically necessary.

23700

 

 

 

 

 

 




MUA of the Ankle, Elbow, Finger, Hip, Pelvic Ring, Spine, and Wrist

MUA of the ankle, elbow, finger, hip, pelvic ring, spine, and wrist is considered not medically necessary.

22505

24300

25259

26340

27198

27275

27860




Documentation Requirements

The medical record should include the following documentation:

  • Failure of condition to respond to conservative therapy, (i.e., physical therapy and joint injections); and
  • Evidence of decreased range of motion; and
  • Length of time that the individual has been symptomatic.

Related Policies

Refer to Medical Policy V-23, Temporomandibular Joint (TMJ) Dysfunction, for additional information.


Covered Diagnosis Codes for Procedure Code 27570

M24.661

M24.662

Z96.651

Z96.652

Z96.653

 

 

Covered Diagnosis Codes for Procedure Code 23700

M75.01

M75.02

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Manipulation Under Anesthesia is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.