Medical Necessity Guidelines: Percutaneous Left Atrial Appendage Closure to Reduce Stroke Risk in Patients with Atrial Fibrillation

Medical Necessity Guidelines: Percutaneous Left Atrial Appendage Closure to Reduce Stroke Risk in Patients with Atrial Fibrillation
Atrial fibrillation (AF) is a rapid, irregularly irregular atrial cardiac rhythm brought on when the two
upper chambers (atria) of the heart no longer contract together in a coordinated manner. AF is one of
the most common arrhythmias, affecting about 2.3 million adults in the US. Prevalence increases with
age; almost 10% of people over the age of 80 are affected. AF tends to occur in patients with a heart
disorder. Atrial thrombi often form in patients with AF due to the slowing of blood flow that results
when the atria no longer contract normally, causing a significant risk of embolic stroke.
The WATCHMAN LAA closure technology consists of a delivery catheter and a device that is
permanently implanted in the left atrial appendage (LAA) of the heart. The device, often referred to as
the WATCHMAN, prevents LAA blood clots from entering the bloodstream and potentially causing a
stroke. It is used in patients who have atrial fibrillation not related to heart valve disease.

CLINICAL COVERAGE CRITERIA
Tufts Health Plan may cover percutaneous left atrial appendage (LAA) closure using the Watchman
device when medically necessary to reduce the risk of thromboembolism from the LAA in patients with
nonvalvular atrial fibrillation who:
• Are at increased risk for stroke and systemic embolism;
• Are recommended for anticoagulation therapy;
• Are deemed by their physicians to be suitable for warfarin; and
• Have an appropriate rationale to seek a non-pharmacologic alternative to warfarin, taking into
account the safety and effectiveness of the device compared to warfarin.

LIMITATIONS
Percutaneous left atrial appendage closure using any device other than the WATCHMAN device is
considered investigational and, therefore, not covered (including but not limited to Amplatzer Cardiac
Plug (ACP), Amplatzer Amulet, and Lariat suture delivery device). Please also refer to the Medical
Necessity Guideline: Noncovered Investigational Services.

CODES
Table 1: CPT Codes

CPT Code Description
33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial
implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial
angiography, left atrial appendage angiography, when performed, and radiological
supervision and interpretation

ICD-10 diagnosis codes associated with the above procedure code(s) include:
Table 2: ICD-10 Codes
ICD-10 Code Description
I48.0 Paroxysmal atrial fibrillation
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation

Acupuncture and reimbursement policy for CPT codes

Acupuncture and reimbursement policy for CPT codes
The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract
or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves
the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required
by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and
all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member
specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are
any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and
the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or
Certificate of Coverage will govern.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in
administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent
professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or
medical advice.

APPLICABLE LINES OF BUSINESS/PRODUCTS
This policy applies to Oxford Commercial plan membership.

APPLICATION
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500)
or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network
physicians and other qualified health care professionals, including, but not limited to, non-network authorized and
percent of charge contract physicians and other qualified health care professionals.

OVERVIEW
This policy defines the maximum time unit of service (UOS) for Acupuncture services for face-to-face contact with the
patient, addresses supplies that are included in the Acupuncture services and describes the submission of evaluation
and management services in conjunction with Acupuncture services.
All services described in this policy may be subject to additional Oxford reimbursement policies including, but not
limited to, the Maximum Frequency Per Day and the Supply Policy.


REIMBURSEMENT GUIDELINES

This policy enforces the code description for Acupuncture services which are to be reported based on 15 minute time
increments of personal face-to-face contact with the patient and not the duration of the needle(s) placement. In
addition, CPT® code guidelines state only one initial CPT code, 97810 or 97813, should be reported per day.
In accordance with the code descriptions and/or the Centers for Medicare and Medicaid Services (CMS) guidelines and
CMS Medicaid National Correct Coding Initiative (NCCI) established Medically Unlikely Edits (MUE) values, the
maximum units of Acupuncture services allowed per date of service are as follows:

CPT/HCPCS Code Medically Unlikely Edits (MUE) values
97810 1
97811 3
97813 1
97814 2
S8930 3

The cost of needles (A4212 and A4215) is included in the Acupuncture service and will be denied if submitted in
addition to the Acupuncture service. The CMS National Physician Fee Schedule (NPFS) indicates these supplies are
part of the Practice Expense (PE) and should not be reported separately.
Consistent with the CPT code description and the CMS NCCI Procedure to Procedure Coding Edits (PTP), electrical
stimulation services (97014, 97032, and G0283) should not be reported separately in addition to specific Acupuncture
services that include electrical stimulation (97813, 97814 and S8930). A modifier may be appropriate when an
electrical stimulation service is performed distinctly and separate from the Acupuncture service and the
documentation supports the service was not related to the Acupuncture.
Per CPT guidelines an evaluation and management (E/M) service may only be reported in addition to Acupuncture
services if the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual
pre-service and post-service work associated with the Acupuncture service. When a separate E/M service is reported,
the time spent for the E/M service is not to be included in the time UOS for the Acupuncture service.

DEFINITIONS

Acupuncture: Technique for treating certain painful conditions and for producing regional anesthesia by passing long
thin needles through the skin to specific points.

APPLICABLE CODES
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all
inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan
document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply
any right to reimbursement or guarantee claim payment. Other Policies may apply.

CPT Code Description
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15
minutes
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient
97811
Acupuncture, 1 or more needles; without electrical stimulation, each additional 15
minutes of personal one-on-one contact with the patient, with re-insertion of the
needle(s) (List separately in addition to code for primary procedure)
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient
97814
Acupuncture, 1 or more needles; with electrical stimulation, each additional 15
minutes of personal one-on-one contact with the patient, with re-insertion of
needle(s) (List separately in addition to code for primary procedure)



HCPCS Code Description
A4212 Noncoring needle or stylet with or without catheter
A4215 Needle, sterile, any size, each
G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than
wound care, as part of a therapy plan of care
S8930 Electrical stimulation of auricular Acupuncture points; each 15 minutes of personal
one-on-one contact with patient

Coding Guideline for Synagis® (palivizumab)

Coding Guideline for Synagis® (palivizumab)

CPT© Code: 90378
Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
Criteria for Coverage
Synagis® (palivizumab) will be allowed monthly during the RSV season, October 19th – April 21st
.
Prior Authorization
Prior Authorization must be obtained through Health Information Designs by completing the online
form found at; http://hidesigns.com/ndmedicaid/pa-forms.html - choose Synagis Registration Form
The ND MMIS Service Authorization Number located on the approval letter must be entered on the
claim at the time of submission. Failure to do so will result in claim denial.
Coding and Billing Instruction
CPT© 90378 must be billed electronically via an 837P transaction with the correlating NDC code for
the Synagis® administered.
Synagis® is available in both 50 mg and 100 mg vials. Multiple vial dosages should be reported with
the most accurate combination to reflect the actual amount of drug administered. Each unique NDC
must be reported on a separate line on the 837P with the correlating number of HCPCS units.
Effective for dates of service on or after 10/19/2018 standard National Correct Coding Initiative
(NCCI) Procedure to Procedure (PTP) editing will be applied to the administration code (CPT 96372)
and Evaluation and Management (E/M) Service combination when rendered on the same date of
service by the same provider.


References:
https://www.nd.gov/dhs/services/medicalserv/medicaid/docs/cpt/synagis-coding-guidelines.pdf

Coding Guidelines for Laboratory CPT codes

Coding Guidelines for Laboratory CPT codes
Urine Culture, Bacterial
1. Specific coding guidelines:
a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine
culture colony count is performed to determine the approximate number of bacteria
present per milliliter of urine. The number of units of service is determined by the
number of specimens.
b. Use CPT 87088 where a commercial kit uses manufacturer defined media for
isolation, presumptive identification, and quantitation of morphotypes present. The
number of units of service is determined by the number of specimens.
c. Use CPT 87088 where identification of morphotypes recovered by quantitative
culture or commercial kits and deemed to represent significant bacteriuria requires
the use of additional testing, for example, biochemical test procedures on colonies.
Identification based solely on visual observation of the primary media is usually not
adequate to justify use of this code. The number of units of service is determined
by the number of isolates.
d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be
significant is performed concurrently with identification. The number of units of
service is determined by the number of isolates. These codes are not exclusively
used for urine cultures but are appropriate for isolates from other sources as well.
e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088,
1 per isolate and 87184 or 87186 where appropriate.
f. Culture for other specific organism groups not ordinarily recovered by media used
for aerobic urine culture may require use of additional CPT codes (for example,
anaerobes from suprapubic samples).
g. Identification of isolates by non-routine, nonbiochemical methods may be coded
appropriately (for example, immunologic identification of streptococci, nucleic acid
techniques for identification of N. gonorrhoeae).
h. While infrequently used, sensitivity studies by methods other than CPT 87184 or
87186 are appropriate. CPT 87181, agar dilution method, each antibiotic or CPT
87188, macrotube dilution method, each antibiotic may be used. The number of
units of service is the number of antibiotics multiplied by the number of unique
isolates.


2. ICD-9-CM code 780.02, 780.9 or 799.3 should be used only in the situation of an
elderly patient, immunocompromised patient or patient with neurologic disorder who
presents without typical manifestations of a urinary tract infection but who presents with
one of the following signs or symptoms, not otherwise explained by another co-existing
condition: increasing debility; declining functional status; acute mental changes;
changes in awareness; or hypothermia.
3. In cases of post renal-transplant urine culture used to detect clinically significant occult
infection in patients on long term immunosuppressive therapy, use code V58.69.

190.13 – Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)


1. Specific coding guidelines:
a. Temporary code G0100 has been superseded by code 87536 effective January 1,
1998.
b. CPT codes for quantification should not be used simultaneously with other nucleic
acid detection codes for HIV-1 (that is, 87534, 87535) or HIV-2 (that is, 87537,
87538).
2. Codes 647.60-647.64 should only be used for HIV infections complicating pregnancy.


190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
1. Specific coding guidelines:
a. CPT 86701 or 86703 is performed initially. CPT 86702 is performed when 86701 is
negative and clinical suspicion of HIV-2 exists.
b. CPT 86689 is performed only on samples repeatedly positive by 86701, 86702, or
86703.
c. CPT 87534 or 87535 is used to detect HIV-1 RNA where indicated. CPT 87537 or
87538 is used to detect HIV-2 RNA where indicated.


190.16 – Partial Thromboplastin Time (PTT)
1. When patients are being converted from heparin therapy to warfarin therapy, use code
V58.61 to document the medical necessity of the PTT.
2. When coding for Disseminated Intravascular Coagulation (DIC), use 286.6 or code for
the signs and symptoms clinically indicating DIC.
3. If a specific condition is known and is the reason for a pre-operative test, submit the
clinical text description or ICD-9-CM code describing the condition with the
order/referral. If a specific condition or disease is not known, and the pre-operative test
is for pre-operative clearance only, assign code V72.84.
4. Assign codes 289.8 – other specified disease of blood and blood-forming organs only
when a specific disease exists and is indexed to 289.8, (for example, myelofibrosis).


Do not assign code 289.8 to report a patient on long term use of anticoagulant therapy
(for example, to report a PTT value or re-check need for medication adjustment.)
Assign code V58.61 to referrals for PTT checks or re-checks. (Reference AHA’s
Coding Clinic, March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)


190.17 – Prothrombin Time (PT)
1. If a specific condition is known and is the reason for a pre-operative test, submit the
text description or ICD-9-CM code describing the condition with the order/referral. If a
specific condition or disease is not known, and the pre-operative test is for preoperative clearance only, assign code V72.84.
2. Assign codes 289.8 – other specified disease of blood and blood-forming organs only
when a specific disease exists and is indexed to 289.8 (for example, myelofibrosis). Do
not assign code 289.8 to report a patient on long term use of anticoagulant therapy
(e.g. to report a PT value or re-check need for medication adjustment.) Assign code
V58.61 to referrals for PT checks or re-checks. (Reference AHA’s Coding Clinic,
March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)


190.19 – Collagen Crosslinks, Any Method
1. When the indication for the test is long-term administration of glucocorticosteroids, use
ICD-9-CM code V58.69.


190.20 – Blood Glucose Testing
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context
of the documentation in the medical record in order to assign the most accurate ICD-9-
CM code. An abnormally elevated fasting blood glucose level in the absence of the
diagnosis of diabetes is classified to Code 790.6 - other abnormal blood chemistry. If
the provider bases the diagnostic statement of impaired glucose tolerance” on an
abnormal glucose tolerance test, the condition is classified to 790.2 -- normal glucose
tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes
mellitus.
2. When a patient is under treatment for a condition for which the tests in this policy are
applicable, the ICD-9-CM code that best describes the condition is most frequently
listed as the reason for the test.
3. When laboratory testing is done solely to monitor response to medication, the most
accurate ICD-9-CM code to describe the reason for the test would be V58.69 -- long
term use of medication.
4. Periodic follow-up for encounters for laboratory testing for a patient with a prior history
of a disease, who is no longer under treatment for the condition, would be coded with
an appropriate code from the V67 category -- follow-up examination.
5. According to ICD-9-CM coding conventions, codes that appear in italics in the
Alphabetic and/or Tabular columns of ICD-9-CM are considered manifestation codes
that require the underlying condition to be coded and sequenced ahead of the
manifestation. For example, the diagnostic statement, “thyrotoxic exophthalmos
(376.21),” which appears in italics in the tabular listing, requires that the thyroid
disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos.
Therefore, a diagnostic statement that is listed as a manifestation in ICD-9-CM must be
expanded to include the underlying disease in order to accurately code the condition.


190.21 – Glycated Hemoglobin/Glycated Protein
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context
of the documentation in the medical record in order to assign the most accurate ICD-9-
CM code. An abnormally elevated fasting blood glucose level in the absence of the
diagnosis of diabetes is classified to Code 790.6 - other abnormal blood chemistry. If
the provider bases the diagnostic statement of impaired glucose tolerance” on an
abnormal glucose tolerance test, the condition is classified to 790.2 -- normal glucose
tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes
mellitus.


190.22 – Thyroid Testing
1. When a patient is under treatment for a condition for which the tests in this policy are
applicable, the ICD-9-CM code that best describes the condition is most frequently
listed as the reason for the test.
2. When laboratory testing is done solely to monitor response to medication, the most
accurate ICD-9-CM code to describe the reason for the test would be V58.69 - long
term use of medication.
3. Periodic follow-up for encounters for laboratory testing for a patient with a prior history
of a disease, who is no longer under treatment for the condition, would be coded with
an appropriate code from the V67 category -- follow-up examination.
4. According to ICD-9-CM coding conventions, codes that appear in italics in the
Alphabetic and/or Tabular columns of ICD-9-CM are considered manifestation codes
that require the underlying condition to be coded and sequenced ahead of the
manifestation. For example, the diagnostic statement “thyrotoxic exophthalmos
(376.21),” which appears in italics in the tabular listing, requires that the thyroid
disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos.
Therefore, a diagnostic statement that is listed as a manifestation in ICD-9-CM must be
expanded to include the underlying disease in order to accurately code the condition.
5. Use code 728.9 to report muscle weakness as the indication for the test. Other
diagnoses included in 728.9 do not support medical necessity.
6. Use code 194.8 (Malignant neoplasm of other endocrine glands and related structures,
other) to report multiple endocrine neoplasia syndromes (MEN-1 and MEN-2). Other
diagnoses included in 194.8 do not support medical necessity.


190.26 – Carcinoembryonic Antigen
1. To show elevated CEA, use ICD-9-CM 790.99 (Other nonspecific findings on
examination of blood) only if a more specific diagnosis has not been made. If a more
specific diagnosis has been made, use the code for that diagnosis.


190.31 – Prostate Specific Antigen
1. To show elevated PSA, use ICD-9-CM code 790.93 (Elevated prostate specific
antigen). If a more specific diagnosis code has been made, use the code for that
diagnosis.


References:
http://healthnetworklabs.com/pdf/5Additional%20Coding%20Guidelines.pdf

Manipulation Procedure/CPT codes Under Anesthesia

Manipulation Procedure/CPT codes Under Anesthesia

Overview
This Coverage Policy addresses manipulation under anesthesia (MUA).


Coverage Policy
A single treatment of manipulation under anesthesia* (MUA) is considered as medically necessary for
ANY of the following indications:
• adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management,
including medications with or without articular injections, home exercise programs and physical
therapy (Common Procedural Terminology [CPT] code 23700)
• post-traumatic or postoperative arthrofibrosis of the knee (e.g., total knee replacement, anterior
cruciate ligament repair) (CPT code 27570) when there is failure of conservative medical
management, including exercise and physical therapy
• reduction of a displaced fracture (e.g., vertebral, long bones) (e.g., CPT code 22505, 25675)
• reduction of acute/traumatic dislocation (e.g., vertebral, perched cervical facet) (e.g., CPT code
22505)
• chronic contracture of upper or lower extremity joint (e.g., fixed contracture from a neuromuscular
condition) when there is failure of conservative medical management including range of motion
exercise programs and physical therapy

MUA provided for these indications consists of a SINGLE treatment session. Repeat treatment
sessions involving a previously treated bone or joint are subject to medical necessity review.
Furthermore, serial treatment sessions (i.e., treatments of the same bone/joint provided
subsequently over a period of time) are not in accordance with generally accepted standards of
medical practice and are therefore not medically necessary.
MUA for any other indication, including the treatment of acute or chronic pain conditions, involving one
or more of the following joints, is considered experimental, investigational or unproven:
• ankle (CPT code 27860)
• cervical, thoracic or lumbar spine (e.g., CPT code 22505)
• elbow (CPT code 24300)
• finger (e.g., CPT code 26340, 26675)
• hip (CPT code 27275)
• pelvis, sacroiliac (CPT code 27198)
• temporomandibular (CPT code 21073)
• thumb (CPT code 26340)
• toe (CPT code 28635, 28665)
• wrist (CPT code 25259

General Background
Manipulation under anesthesia (MUA) is aimed at reducing pain and improving range of motion and is a
treatment modality that consists of manipulation and stretching procedures performed while an individual
receives anesthesia (e.g., conscious sedation, general anesthesia). A chiropractor, osteopathic physician or
medical physician may perform this type of manipulation with an anesthesiologist in attendance.
MUA is considered a safe and effective form of treatment for some joint conditions, such as arthrofibrosis of the
knee and adhesive capsulitis. It is also utilized for treatment of fractures (e.g., vertebral, long bones) and
dislocations. Although there is limited evidence in the peer-reviewed medical literature supporting safety and
efficacy for the treatment of pain conditions, MUA has been recommended as a treatment modality for acute and
chronic pain conditions, particularly of the spinal region, when standard chiropractic care and other conservative
measures have proved unsuccessful.
An individual’s protective reflex mechanism is absent under anesthesia and proponents contend it is less difficult
to separate and move the joint when the reflex is absent. During MUA, the chiropractor or physician performs a
combination of short manipulations, passive stretches and maneuvers to break up fibrous and scar tissue around
the spine and surrounding joint areas. This manipulation typically includes a high velocity thrust (i.e., a technique
that adjusts the joints rapidly), which may be followed by a popping or snapping sound.
In a less frequently used technique, manipulation under anesthesia (MUA) may be accompanied by
fluoroscopically-guided intra-articular injections with corticosteroid agents to reduce inflammation. This procedure
is referred to as manipulation under joint anesthesia/analgesia (MUJA). Manipulation under epidural anesthesia
(MUEA) employs an epidural, segmental anesthetic, often with simultaneous epidural steroid injections, followed
by spinal manipulation therapy. Some therapies may combine manipulation with cortisone injections into
paraspinal tissues and proliferant injections. Other forms of manipulation under anesthesia include spinal
manipulation under anesthesia (SMUA) performed with or without manipulation of other joints and total body joint
manipulation.
MUA is considered safe and effective and is a well-established method of treatment for conditions such as
adhesive capsulitis of the shoulder, arthrofibrosis of the knee, and some fractures, dislocations and contractures.
When performed for these specific conditions, MUA generally requires a single session of treatment, most often
performed unilaterally, involving a single joint. Data supporting the need for, and clinical efficacy of multiple,
repeat MUA treatment sessions for these specific conditions, is lacking in the peer-reviewed published medical
literature.

Adhesive Capsulitis/Frozen Shoulder
Adhesive capsulitis, also referred to as frozen shoulder, is used to describe a painful restriction (both passive
and active) of shoulder motion in an individual whose radiographs are typically normal. It may also be referred to
as pericapsulitis and occurs in approximately 2-5% of the general population. Some authors contend the
condition results from synovial inflammation with subsequent reactive capsular fibrosis. Early stages are treated
with steroid injections and home therapy. For refractory cases, more aggressive treatment involves manipulation
of the shoulder joint under anesthesia or an arthroscopic capsular release (Griffen, 2003). Manipulating the joint
under anesthesia breaks up the adhesions surrounding the joint and stretches the fibrotic tissue thereby
increasing joint motion and reducing pain. Evidence in the peer-reviewed published scientific literature, including
textbook sources, supports MUA may be considered for refractory cases of adhesive capsulitis of the shoulder
MUA is generally recommended for individuals who do not respond to or who
demonstrate little improvement after conservative treatment.

Postoperative/Post-traumatic Arthrofibrosis of the Knee
Arthrofibrosis of the knee is a condition that may occur following trauma, surgery or joint replacement and results
from inflammation and proliferation of scar tissue. Physiologically, traumatic injury to the knee leads to the
formation of internal scar tissue with shrinking and tightening of the joints knee capsule. Tendons outside the
joint may also shrink and tighten, leading to a further decrease of joint mobility. Treatment of arthrofibrosis of the
knee begins with physical therapy to improve motion, for refractory cases manipulation of the joint under
anesthesia may be performed. However in some cases manipulation of the joint inadvertently results in femoral
or tibial fracture, depending on the severity of adhesion formation and weak joints. As a result, some surgeons
perform an arthroscopic internal resection of scar tissue prior to manipulating the joint in order to reduce the
manipulation force and prevent fractures. MUA is indicated, with or without arthroscopy for arthrofibrosis of the
knee, when there is < 90° range of motion following surgery or trauma despite physical therapy (Magit, et al.
2007). Published evidence in the medical literature supports MUA as a well-established safe and effective
treatment for arthrofibrosis of the knee

Postoperative/Post-traumatic Arthrofibrosis of the Elbow
Arthrofibrosis of the elbow often occurs following injury (e.g., operative, fracture). The elbow becomes stiff as a
result of soft-tissue contracture of the ligaments, muscles and/or tendons. Early management generally involves
bracing and splints (Araghi, et al, 2010). Manipulation under anesthesia may be recommended when there is
failure to progress improve and progress following the use of bracing. Operative release may be considered a
treatment option depending on the cause of the contracture, the presence of pain or other symptoms, and
decrease in functional level.
Published evidence in the peer reviewed scientific literature supporting the safety and effectiveness of using
manipulation under anesthesia of the elbow is limited to retrospective case series, involve small sample
populations and lack control groups (Rotman, et al, 2019; Spitler, et al., 2018; Araghi, et al, 2012, Duke, et al.,
1991, Davilia, Johnston-Jones, 2006; Tan, et al., 2006; Chao, et al, 2002; Gaur, et al, 2003). Few studies lend
support to clinical effectiveness for the treatment of joint stiffness/fibrosis when other conservative measures,
such as bracing and splinting, have failed to improve range of motion. In addition, evidence-based clinical
practice guidelines supporting MUA for arthrofobrosis of the elbow are not available. There is insufficient
evidence in the peer-reviewed published literature and lack of consensus among professional societies to
support the effectiveness of MUA as treatment for arthrofibrosis of the elbow

Fracture and/or Dislocation
MUA is also considered a well-established and successful treatment for some types of fractures (e.g., vertebral,
long bones) and acute/traumatic dislocations (e.g., perched cervical facet). It is typically performed with surgical
Page 4 of 13
Medical Coverage Policy: 0276
repair and other medically necessary procedures such as arthroscopy. When performed in this context, MUA is
considered incidental to the base procedure.


Chronic Contracture of Upper or Lower Extremity Joint
A joint contracture is a limitation in the passive range of motion of a joint. Joint contractures prevent normal
movement of the associated body part and can result from a variety of causes such as spasticity or prolonged
immobilization. Intra-articular adhesions and peri-articular adhesions, as well as capsular, ligament and muscle
shortening and tightness may develop. As a result, activities of daily living and other skills may be adversely
affected due to the decreased mobility. In many cases, contractures can be successfully treated nonoperatively
with aggressive physical therapy or splinting with restoration of functional range of motion. When conservative
treatment fails more aggressive treatment may necessary and includes anesthetic block, maximal stretching, and
in some cases, serial casting (Garden, 2002). For joint contracture deformities, extra-articular and intra-articular
soft tissue releases are considered standard treatment (Paley, 2003). Surgical treatments include tenotomy,
tendon lengthening and joint capsule release. Manipulation under anesthesia, involving maximal passive
stretching may be considered standard treatment and is often performed in combination with serial casting
and/or surgical release when less aggressive treatments have failed.


Pain Management
Although not well-supported in the peer-reviewed published scientific literature, manipulation under anesthesia
has been proposed as a treatment for spine-related pain conditions, including but not limited to, acute or chronic
cervical pain, cervicobrachial, cervicocranial, lumbar, pelvis, or lower extremity syndromes with somatic
dysfunctions that have not responded to conservative management. Manipulation under anesthesia for pain
management often involves the spine and/or other major body joints in addition to the spine. Individuals typically
undergo a 4 to 8 week trial of conservative manipulation management (e.g., chiropractic care) prior to more
aggressive approaches, such as MUA. Authors contend failure of a trial of conservative therapy is thought to be
the primary basis for more aggressive MUA approaches (Kohlbeck, et al., 2002).
When utilized for pain management, MUA treatment typically consists of consecutive daily treatment sessions,
(generally one to five sessions, with three being the average), followed by additional outpatient chiropractic
sessions and may or may not be accompanied by steroid injections. During the procedure, manipulation of
various joints, including the spine, may be performed as part of the overall therapy plan. Cremata and associates
(2005) identified three distinct stages to MUA: sedation of the patient, specific chiropractic adjustments, and
passive stretching and traction procedures of the spine, sacroiliac and pelvis. The literature suggests maneuvers
are predetermined for each individual patient but often involves all regions of the spine (i.e., cervical, thoracic,
lumbar) as well as distal extremities and that the need for serial manipulations is determined by the degree of
biomechanical function following the initial procedure. However, there is insufficient evidence in the peerreviewed published scientific literature to support safety and efficacy of MUA for the management of acute or
chronic pain conditions, when performed as single or multiple treatment sessions.


Spine: Theoretically, spinal manipulation as a method of treatment for subluxation stretches the joint capsules
and resets the spinal cord and nerve position, allowing the nervous system to function optimally. Evidence in the
published, peer-reviewed scientific literature has failed to demonstrate the safety and efficacy of MUA when used
for the treatment of pain associated with the spine (SMUA) and some sources indicate the treatment may be
hazardous and is obsolete (Kohatsu, 2007; Lindsey, et al., 2003). In addition, anesthesia itself carries a small but
clinically significant risk. Overall, the evidence evaluating SMUA consists mainly of case reports, case series, few
controlled clinical trials and literature reviews (Peterson, et al., 2014; Taber, et al., 2013; Cremata, et al., 2005;
Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002; Kohlbeck and Haldeman, 2002; West, et al., 1999). Some of
the study results support improvement in pain and function following SMUA when compared to traditional
manipulation (Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002); however these studies are limited by lack of
randomization, small sample populations and measurement of short-term outcomes. Follow-up assessments
were generally conducted from three months to one year post-MUA treatment, some of which consisted of selfreported outcomes and questionnaires. Patient selection criteria are poorly defined and treatment protocols vary
making comparisons difficult. Much of the evidence evaluating SMUA is low quality and reliable conclusions
cannot be drawn regarding efficacy and improvement of health outcomes. Further well-designed clinical trials are
needed to support the safety and effectiveness of the procedure for the management of acute or chronic pain
conditions related to the spine.
Medical Coverage Policy: 0276


Other Joints: Evidence in the medical literature evaluating the use of MUA for management of pain conditions
involving one or more (i.e., multiple joints, whole body MUA) of other major joints such as the hip, ankle, toe,
elbow, and wrist, is lacking. Due to insufficient evidence conclusions cannot be made regarding the clinical utility
or safety and efficacy of MUA involving other single or multiple joints for pain management.
Other Conditions
There is insufficient evidence in the peer-reviewed published scientific literature to support safety and efficacy of
manipulation under anesthesia of any joint such as the hip, ankle, toe, elbow, and wrist for the treatment of any
other condition.
Professional Societies/Organizations
Published guidelines on the diagnosis and treatment of neck, upper back and low back pain prepared by the
Work Loss Data Institute (WLDI) both address MUA; MUA is listed in both documents as a procedure that was
evaluated and that is not recommended (Work Loss Data Institute, 2013a, 2013b).
According to the American College of Occupational and Environmental Medicine (ACOEM) practice guidelines
regarding physical methods of treatment for low back disorders (Hegmann, 2007; update: Hegmann, et al.,
2008), due to insufficient evidence manipulation under anesthesia (MUA) and medication-assisted spinal
manipulation (MASM) for acute, subacute or chronic low back pain is not recommended.
Centers for Medicare & Medicaid Services (CMS)
• National Coverage Determinations (NCDs): A CMS NCD Manipulation (150.1) is less broad in scope.
Please reference the CMS NCD table of contents link in the reference section.
• Local Coverage Determinations (LCDs): A CMS LCD Manipulation Under Anesthesia (MUA) (L33594) is
less broad in scope. Please reference the CMS LCD table of contents link in the reference section.
Use outside the US
No relevant information.


Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
 2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
 for reimbursement.
Coverage is limited to a SINGLE treatment session of an isolated joint condition.


SHOULDER
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)


SPINE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
22505 Manipulation of spine requiring anesthesia, any region

PELVIS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation
of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s)
and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or
bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia,
moderate sedation, spinal/epidural)


ARM
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
24300 Manipulation, elbow, under anesthesia
24605 Treatment of closed elbow dislocation; requiring anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation


WRIST
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
25259 Manipulation, wrist, under anesthesia
25690 Closed treatment of lunate dislocation, with manipulation
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint; requiring anesthesia


HAND /FINGERS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
26340 Manipulation, finger joint, under anesthesia, each joint
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989† Unlisted procedure, hands or fingers
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
†Note: Covered when medically necessary when used to report MUA of a finger or thumb
requiring anesthesia.
Medical Coverage Policy: 0276


HIP
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia
27275 Manipulation, hip joint, requiring general anesthesia


LEG
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27831 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia


KNEE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27552 Closed treatment of knee dislocation; requiring anesthesia
27562 Closed treatment of patellar dislocation; requiring anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)


ANKLE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28545 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia


FOOT/TOES
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
Experimental, investigational or unproven when used to report manipulation under anesthesia of a
single joint or multiple body joints for any other condition, including the management of acute or chronic
pain conditions:
Medical Coverage Policy: 0276


CPT®* Codes Description
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia
service (ie, general or monitored anesthesia care)
22505 Manipulation of spine requiring anesthesia, any region
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)
24300 Manipulation, elbow, under anesthesia
25259 Manipulation, wrist, under anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation
25690 Closed treatment of lunate dislocation, with manipulation
26340 Manipulation, finger joint, under anesthesia, each joint
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint, requiring anesthesia
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989 Unlisted procedure, hands or fingers
27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation
of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s)
and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or
bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia,
moderate sedation, spinal/epidural)
27275 Manipulation, hip joint, requiring general anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
*Current Procedural Terminology (CPT®) ©2017 American Medical Association: Chicago, IL




References:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0276_coveragepositioncriteria_spinal_manipulation_under_anesthesia.pdf