Latest Review Date: May 2023

Category:  Therapy                                                               

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 is considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain.

Spinal manipulation under anesthesia involving serial treatment sessions is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

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).

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. Manipulation under anesthesia is an accepted treatment for isolated joint conditions, such as arthrofibrosis of the knee and adhesive capsulitis. It is also used to reduce fractures (e.g., vertebral, long bones) and dislocations.

Manipulation under anesthesia 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. Manipulation under anesthesia 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. Manipulation under anesthesia 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.

Manipulation under anesthesia 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 ta 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. 

Manipulation under anesthesia takes 15 to 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 three or more consecutive days for best results. Care after MUA may include four to eight 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 post-epidural injection [MUES]}/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).

For joint manipulation under anesthesia for joints excluding spine, refer to policy #345 Joint Manipulation under Anesthesia (Excluding Spine).

This policy does not address the use of spinal manipulation under anesthesia for the treatment of vertebral fracture or dislocation.

KEY POINTS:

The most recent update with literature review was performed using the MEDLINE database through February 24, 2023.

Summary of Evidence

For individuals who have chronic spinal, sacroiliac, or pelvic pain who receive MUA, the evidence includes case series and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Scientific evidence on spinal MUA, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is very limited. No randomized controlled trials have been identified. Evidence on the efficacy of MUA over several sessions or for multiple joints is also lacking. Safety outcomes in these settings are poorly described. The evidence is insufficient to determine the effects of the technology on health outcomes.

PRACTICE GUIDELINES AND POSITION STATEMENTS

American Association of Manipulation Under Anesthesia Providers

The American Association of Manipulation Under Anesthesia Providers (2014) published consensus-based guidelines for the practice and performance of manipulation under anesthesia (MUA). The guidelines included patient selection criteria, establishing medical necessity, frequency and follow-up procedures, parameters for determining MUA progress, general post-MUA therapy, and safety. The guidelines recommended 3 consecutive days of treatment, based on the premise that serial procedures allow a gentler yet effective treatment plan with better control of biomechanical force. The guidelines also recommended follow-up therapy without anesthesia over 8 weeks after MUA that includes all fibrosis release and manipulative procedures performed during the MUA procedure to help prevent re-adhesion.

Patient selection criteria include, but are not limited to, the following:

• "The patient has undergone an adequate trial of appropriate care...and continues to experience intractable pain, interference to activities of daily living, and/or biomechanical dysfunction.
• "Sufficient care has been rendered prior to recommending MUA. A sufficient time period is usually considered a minimum of 4-8 weeks, but exceptions may apply depending on the patient's individual needs....
• "Physical medicine procedures have been utilized in a clinical setting during the 6-8 week period prior to recommending MUA.
• "Diagnosed conditions must fall within the recognized categories of conditions responsive to MUA. The following disorders are classified as acceptable conditions for utilization of MUA:

1. "Patients for whom manipulation of the spine or other articulations is the treatment of choice; however, the patient's pain threshold inhibits the effectiveness of conservative manipulation.

 2. "Patients for whom manipulation of the spine or other articulations is the treatment of choice; however, due to the extent of the

injury mechanism, conservative manipulation has been minimally effective...and a greater degree of movement of the affected joint(s) is needed to obtain patient progress.

3. "Patients for whom manipulation of the spine or other articulations is the treatment of choice by the doctor; however due to the chronicity of the problem, and/or the fibrous tissue adhesions present, in-office manipulation has been incomplete and the plateau in the patient's improvement is unsatisfactory.

4. "When the patient is considered for surgical intervention, manipulation under anesthesia is an alternative and/or an interim treatment and may be used as a therapeutic and/or diagnostic tool in the overall consideration of the patient's condition.

5. "When there are no better treatment options available for the patient in the opinions of the treating doctor and patient."

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

The U.S. Preventive Services Task Force has not addressed MUA.

KEY WORDS:

Spinal manipulation under anesthesia, SMUA, pelvic pain, MUA, MAM

APPROVED BY GOVERNING BODIES:

Manipulative procedures are not subject to regulation by the U.S. Food and Drug Administration.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  Special benefit may apply. Refer to member’s benefit plan.  

CODING:

CPT:

REFERENCES:

1. Dagenais S, Mayer J, Wooley JR and Haldeman S. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J, Jan-Feb 2008; 8(1): 142-149.
2. Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr man Therap 2013; 21(1):14.
3. Dougherty P, Bajwa S, Burke J and Dishman JD. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: A retrospective case series. J Manipulative Physiol Ther, September 2004; 27(7): 449-456.
4. Dreyfuss P, et al. MUJA: Manipulation under joint anesthesia/analgesia: A treatment approach for recalcitrant low back pain of synovial joint origin. Journal of Manipulative and Physiological Therapeutics, October 1995; 18(8): 537-546.
5. Farrar JT, Young JP, LaMoreaux L et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov;94(2).
6. Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014; 22 (1):7.
7. Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther. 2004 Jan;27(1).
8. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
9. Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002; 2(4): 288-302.
10. Kohlbeck FJ, Haldeman S, et al. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther, May 2005; 28(4): 245-252.
11. Michaelsen MR. Manipulation under joint anesthesia/analgesia: A proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin. Journal of Manipulative and Physiological Therapeutics, February 2000; 23(2): 127-129.
12. Palmieri NF and Smoyak S.  Chronic low back pain: A study of the effects of manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics, October 2002; 25(8): E8-E17.
13. Peterson CK, Humphreys BK, Vollenweider R, et al. Outcomes for chronic neck and low back pain patients after manipulation under anesthesia: a prospective cohort study. J Manipulative Physiol Ther. Jul-Aug 2014; 37 (6):377-382.
14. West DT, et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics, June 1999; 22(5): 299-308.

POLICY HISTORY:

Medical Policy Group, March 2004 (1)

Medical Policy Administration Committee, April 2004

Available for comment May 12-June 25, 2004

Medical Policy Group, March 2006 (1)

Medical Policy Group, March 2008 (1)

Medical Policy Group, January 2009 (3): (no review conducted)

Medical Policy Administration Committee, February 2009

Medical Policy Group, March 2010 (1): Policy statement updated, Description, Key Points updated. 

Medical Policy Administration Committee, April 2010

Available for comment April 8-May 23, 2010

Medical Policy Group, June 2010 (3)

Medical Policy Group, October 2010 (1): No changes or updates

Medical Policy Panel, December 2013

Medical Policy Group, January 2014 (2): Policy updated with literature search through November 2013.  Policy statement unchanged.  Description, Key Points, Key Words, and References updated.

Medical Policy Panel, December 2014

Medical Policy Group, December 2014 (4): Updates to Key Points and References. Updated policy statement to include “cervical” for treatment of chronic spinal pain is investigational and added statement for spinal manipulation for serial treatment sessions of MUA being investigational.

Available for comment January 14 through February 27, 2015

Medical Policy Panel, August 2016

Medical Policy Group, August 2016 (7): Updates to Key Points--no new literature updates. No change to policy statement.

Medical Policy Panel, August 2017

Medical Policy Group, September 2017 (7): Updates to Key Points-- no new literature updates. No change to policy statement.

Medical Policy Panel, April 2018

Medical Policy Group, May 2018 (7): Updates to Key Points-- no new literature updates. No change to policy statement.

Medical Policy Panel, April 2019

Medical Policy Group, April 2019 (7): Updates to Key Points-- no new literature updates. No change to policy statement.

Medical Policy Panel, April 2020

Medical Policy Group, April 2020 (7): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No change to Policy Statement.

Medical Policy Panel, April 2021

Medical Policy Group, June 2021 (7): Updates to Key Points and References. No change to Policy Statement.

Medical Policy Panel, April 2022

Medical Policy Group, May 2022 (7): Minor update to Key Points. No new literature updates. No change to Policy Statement.

Medical Policy Group, November 2022 (7): Removed CPT 00640 from Coding Section.

Medical Policy Panel, April 2023

Medical Policy Group, May 2023 (7): Update to Key Points, Benefit Application, and References. No change to Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.