MEDICAL POLICY

POLICY
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DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Manipulation Under Anesthesia

Number 8.01.40

Effective Date December 9, 2013

Revision Date(s) 12/09/13; 12/11/12; 09/13/11; 06/08/10; 06/09/09; 02/12/08; 05/09/06; 05/10/05; 02/10/04; 08/13/02

Replaces N/A

Policy

Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.

Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered investigational.

Manipulation under anesthesia (MUA) involving multiple body joints is considered investigational for treatment of chronic pain.

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

Related Policies

2.01.85

Neural Therapy

7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

7.02.500

Monitored Anesthesia Care (MAC)

8.03.501

Chiropractic Services

Policy Guidelines

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

The CPT code for this procedure is:

22505 Manipulation of spine requiring anesthesia, any region

The CPT code for anesthesia administration is:

00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine

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. Manipulation under anesthesia (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. Together, these may be referred to as medicine-assisted manipulation (MAM).

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

N/A

Rationale

The policy was created with an initial literature search in 2002 and updated periodically using the MEDLINE database. The most recent update with literature search was performed through November 2013. Following is a summary of the key literature to date.

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) or medicine-assisted manipulation (MAM) 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)

No high quality randomized controlled trials have been identified. A 2013 comprehensive review of the literature by DiGiorgi describes studies by Kohlbeck et al. and Palmieri and Smoyak (described below) as being the best evidence available for MAM/MUA or the spine. (2)

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 4.1, 95% CI: 1.3-13.6) and at 1 year (odds ratio 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% vs. 26% in the traditional treatment group; Roland-Morris Questionnaire scores decreased by 51% and 38%, respectively. The authors conclude that the study supports the need for large-scale studies on MUA and that the assessments are easily administered and dependable.

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. (5) 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.

Dougherty et al. retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation post-epidural injection (MUESI). After epidural injection of lidocaine (guided fluoroscopically or with computed cosmography), methylprednisolone acetate glexion distraction mobilization and then high-velocity, low-amplitude spinal manipulation was 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 post-epidural injection in the cervical spine. (6)

The one study of manipulation under joint anesthesia/analgesia (MUJA) found in the literature search had only 4 subjects. (7) 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”. (8)

Searches of the literature using the MEDLINE® database did not find any additional published studies on spinal manipulation under anesthesia involving serial sessions or on manipulation under anesthesia of multiple joints.

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

In response to requests, input was received from 2 physician specialty societies and 4 academic medical centers while this policy was under review in 2009. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. Input from the 7 reviewers agreed that manipulation under anesthesia for chronic spinal and pelvic pain is investigational.

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 investigational.

Practice Guidelines and Position Statements

The American Academy of Osteopathy (AAO)

In 2005, the American Academy of Osteopathy (AAO) published a consensus statement on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. (9) The AAO states that manipulation under anesthesia may be appropriate in cases of restrictions and abnormalities of function that include recurrent muscle spasm, range of motion restrictions, persistent pain secondary to injury and/or repetitive motion trauma, and is in general limited to patients who have somatic dysfunction which:

  • Has failed to respond to conservative treatment in the office or hospital that has included the use of osteopathic manipulative therapy, physical therapy and medication, and/or
  • Is so severe that muscle relaxant medication, anti-inflammatory medication or analgesic medications are of little benefit, and/or
  • Results in biomechanical impairment which may be alleviated with use of the procedure.

The National Academy of Manipulation Under Anesthesia Physicians

In 2002, the National Academy of Manipulation Under Anesthesia Physicians published detailed guidelines for protocols and standards for MUA, including determining the necessity and frequency of MUA. (10)

Medicare National Coverage

Medicare has not published a national coverage decision related to spinal MUA, MUJA, or MUESI.

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. DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap 2013; 21(1):14. Available at URL address: http://www.chiromt.com/content/21/1/14. Last accessed November 2013.
  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:E8-17.
  5. 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.
  6. Dougherty P, Bajwa S, Burkke 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.
  7. 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.
  8. Michaelson 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.
  9. American Academy of Osteopathy. Consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. American Academy of Osteopathy Journal 2005; 15(2):26-27.
  10. National Academy of Manipulation Under Anesthesia Physicians. Purpose statement and protocols and standards. 2002. Available at URL address: http://www.fcghealth.com/pages/mua_phys_corn_national_namua.htm. Last accessed November, 2013.
  11. BlueCross BlueShield Association (BCBSA) Medical Policy Reference Manual, Manipulation under Anesthesia. Medical Policy Reference Manual, Policy No. 8.01.40, 2013.
  12. Reviewed by practicing doctor of chiropractic in November 2013.

Coding

Codes

Number

Description

CPT

00640

Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine

 

22505

Manipulation of spine requiring anesthesia, any region

ICD-9 Procedure

   

ICD-9 Diagnosis

724

Other and unspecified disorders of back

 

739

Nonallopathic lesions, not elsewhere classified code range

 

839

Other, multiple, and ill-defined dislocations code range

ICD-10-CM
(effective 10/01/14)

M47.011-M47.9

Spondylosis code range

 

M54.00 –M54.9

Dorsalgia code range

ICD-10-PCS
(effective 10/01/14)

ORN0XZZ, ORN1XZZ,
ORN3XZZ, ORN4XZZ,
ORN5XZZ, ORN6XZZ,
ORN9XZZ, ORNAXZZ,
ORNBXZZ

Surgical, upper joints, release, external, codes by anatomical location

 

OSN0XZZ, OSN2XZZ,
OSN3XZZ, OSN4XZZ,
OSN5XZZ, OSN6XZZ

Surgical, lower joints, release, external, codes by anatomical location

HCPCS

   

Type of Service

Therapy

 

Place of Service

Outpatient Inpatient

 

Appendix

N/A

History

Date

Reason

08/13/02

Add to Therapy Section - New Policy

02/10/04

Replace policy - Policy updated; no change in policy statement; additional ICD-9 coding information added.

05/10/05

Replace policy - Policy updated with literature search; no change to policy statement.

05/09/06

Replace policy - Policy updated with literature search; policy guidelines section on anesthesia coding updated; no change in policy statement.

06/02/06

Scope and Disclaimer Update - No other changes.

10/9/07

Cross References Updated - No other changes.

02/12/08

Replace Policy - Policy updated with literature search; no change in policy statement.

06/09/09

Replace policy - Policy updated with literature search. Policy statement updated to expand Not Medically Necessary statement, intent unchanged. Policy was updated extensively and title changed from Spinal Manipulation under Anesthesia. References added.

06/08/10

Replace policy - Policy updated with literature search; no change to the policy statement.

09/13/11

Replace policy – Policy updated with literature search through August 2010; title changed to “Manipulation under Anesthesia” to include joints other than the spine; statements added that MUA over multiple sessions or for multiple joints is considered investigational.

05/22/12

Related Policies updated; 10.01.510 removed as this policy was archived.

09/17/12

Update Coding Section – ICD-10 Codes are now effective 10/01/2014. Add Related Policy 2.01.85.

12/19/12

Replace policy. Policy updated with literature search through August 2012; policy statement unchanged. Add Related Policy 7.02.500.

12/09/13

Replace policy. The first Policy statement changed to investigational from not medically necessary. Rationale updated with a literature search through November 2013. Reference 2, 9 -12 added; others renumbered/removed. Added position statements from professional association. Policy statement changed as noted.

01/21/14

Update Related Policies. Add 7.01.551.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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