MEDICAL POLICY I. POLICY II. PRODUCT VARIATIONS POLICY TITLE POLICY NUMBER MANIPULATION UNDER ANESTHESIA MP-8.006

Transcription

1 Original Issue Date (Created): October 04, 2003 Most Recent Review Date (Revised): March 25, 2014 Effective Date: June 1, 2014 I. POLICY Manipulation under anesthesia (MUA) may be considered medically necessary for treatment of isolated joint conditions such as the following; Adhesive capsulitis (i.e., frozen shoulder); Arthrofibrosis of the knee Treat (reduce) s (e.g.vertebral or long bone) and dislocations. Note: MUA of the shoulder or knee should be attempted only after an adequate trial of conservative measures (physical therapy and joint injections) have failed to restore range of motion and relieve pain. Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) while the patient is under anesthesia, spinal manipulation under joint anesthesia, 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. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain, as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [N] SeniorBlue [N] SeniorBlue PPO [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO* Page 1

2 *Refer to FEP Medical Policy Manual MP Manipulation Under Anesthesia for Treatment of Chronic Spinal or Pelvic Pain. The FEP Medical Policy manual can be found at: III. DESCRIPTION/BACKGROUND 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) s (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 longlever, 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 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 Page 2

3 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]). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. IV. RATIONALE 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 (RCT) identified was published in 1971 when the techniques for spinal manipulation were different from those used at the present time. (1) No high-quality RCTs have been identified. A 2013 comprehensive review of the literature describes studies by Kohlbeck et al and Palmieri and Smoyak (described below) as being the best evidence available for MAM/MUA of the spine.(2) Kohlbeck et al 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 SMTonly 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 [OR], 4.1; 95% CI, 1.3 to 13.6) and at 1 year (OR=1.9; 95% CI, 0.6 to 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% versus 26% in the traditional treatment group; Roland-Morris Questionnaire scores decreased by 51% and 38%, respectively. The authors concluded that the study supports the need for large-scale studies on MUA and that the assessments are easily administered and dependable. Page 3

4 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 sedation followed by 4 to 6 weeks of spinal manipulation and therapeutic modalities; all had 6 months of follow-up. On average, visual analog scale 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 postepidural injection. After epidural injection of lidocaine (guided fluoroscopically or with computed tomography), methylprednisolone acetate flexion distraction mobilization and then high-velocity, lowamplitude spinal manipulation were 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 postepidural injection in the cervical spine. (6) The 1 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 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 Page 4

5 Scientific evidence regarding spinal manipulation under anesthesia (MUA), 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) published a consensus statement in 2005 on osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation.(9) AAO states that manipulation under anesthesia may be appropriate in cases of restrictions and abnormalities of function that include recurrent muscle spasm, range-ofmotion restrictions, persistent pain secondary to injury and/or repetitive motion trauma, and is in general limited to patients who have somatic dysfunction which: 1. 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 2. is so severe that muscle relaxant medication, anti-inflammatory medication or analgesic medications are of little benefit, and/or 3. results in biomechanical impairment which may be alleviated with use of the procedure. In 2002, the National Academy of Manipulation Under Anesthesia Physicians published guidelines for protocols and standards for MUA, including determining the necessity and frequency of MUA. (10). V. DEFINITIONS N/A VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. Page 5

6 VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. 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): Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap 2013; 21(1): 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): Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25(8):E8-E 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): Dougherty P, Bajwa S, Burke J et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther 2004; 27(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): Michaelsen 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): 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): National Academy of Manipulation Under Anesthesia Physicians. Purpose statement and protocols and standards Available online at: Last accessed November, Page 6

7 Other: Mohammed R, Syed S, Ahmed N. Manipulation under anaesthesia for stiffness following knee arthroplasty. Ann R Coll Surg Engl. 2009; 91(3): Ng CY, Amin AK, Narborough S, et al. Manipulation under anaesthesia and early physiotherapy facilitate recovery of patients with frozen shoulder syndrome. Scott Med J. 2009; 54(1): Taber s Cyclopedic Medical Dictionary 19 th edition. IX. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Investigational; therefore not covered: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. ICD-9-CM ADHESIVE CAPSULITIS OF SHOULDER Ankylosis of lower leg joint CLOSED FRACTURE OF CERVICAL VERTEBRA WITHOUT MENTION OF SPINAL CORD INJURY Fracture of Radius and Ulna Fracture tibia and fibula Dislocation of Shoulder Page 7

8 Dislocation of Hip Dislocation of Knee Dislocation of Ankle CLOSED DISLOCATION, CERVICAL VERTEBRA CLOSED DISLOCATION, LUMBAR VERTEBRA CLOSED DISLOCATION, THORACIC VERTEBRA CLOSED DISLOCATION, OTHER VERTEBRA *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following ICD-10 diagnosis codes will be effective October 1, 2015: M Ankylosis, right knee M Ankylosis, left knee M Ankylosis, unspecified knee M75.00 Adhesive capsulitis of unspecified shoulder M75.01 Adhesive capsulitis of right shoulder M75.02 Adhesive capsulitis of left shoulder M99.10 Subluxation complex (vertebral) of head region M99.11 Subluxation complex (vertebral) of cervical region M99.12 Subluxation complex (vertebral) of thoracic region M99.13 Subluxation complex (vertebral) of lumbar region M99.14 Subluxation complex (vertebral) of sacral region M99.15 Subluxation complex (vertebral) of pelvic region S12.000a S12.000b S12.001a S12.001b S12.01xa S12.01xb S12.02xa S12.02xb S12.030a S12.030b S12.031a Unspecified displaced of first cervical vertebra, initial encounter for Unspecified displaced of first cervical vertebra, initial encounter for open Unspecified nondisplaced of first cervical vertebra, initial encounter for Unspecified nondisplaced of first cervical vertebra, initial encounter for open Stable burst of first cervical vertebra, initial encounter for Stable burst of first cervical vertebra, initial encounter for open Unstable burst of first cervical vertebra, initial encounter for Unstable burst of first cervical vertebra, initial encounter for open Displaced posterior arch of first cervical vertebra, initial encounter for Displaced posterior arch of first cervical vertebra, initial encounter for open Nondisplaced posterior arch of first cervical vertebra, initial encounter for Page 8

9 S12.031b S12.040a S12.040b S12.041a S12.041b S12.090a S12.090b S12.091a S12.091b S12.100a S12.100b S12.101a S12.101b S12.110a S12.110b S12.111a S12.111b S12.112a S12.112b S12.120a S12.120b S12.121a S12.121b S12.130a S12.130b S12.131a S12.131b S12.14xa S12.14xb S12.150a S12.150b S12.151a Nondisplaced posterior arch of first cervical vertebra, initial encounter for open Displaced lateral mass of first cervical vertebra, initial encounter for Displaced lateral mass of first cervical vertebra, initial encounter for open Nondisplaced lateral mass of first cervical vertebra, initial encounter for Nondisplaced lateral mass of first cervical vertebra, initial encounter for open Other displaced of first cervical vertebra, initial encounter for Other displaced of first cervical vertebra, initial encounter for open Other nondisplaced of first cervical vertebra, initial encounter for Other nondisplaced of first cervical vertebra, initial encounter for open Unspecified displaced of second cervical vertebra, initial encounter for Unspecified displaced of second cervical vertebra, initial encounter for open Unspecified nondisplaced of second cervical vertebra, initial encounter for Unspecified nondisplaced of second cervical vertebra, initial encounter for open Anterior displaced Type II dens, initial encounter for Anterior displaced Type II dens, initial encounter for open Posterior displaced Type II dens, initial encounter for Posterior displaced Type II dens, initial encounter for open Nondisplaced Type II dens, initial encounter for Nondisplaced Type II dens, initial encounter for open Other displaced dens, initial encounter for Other displaced dens, initial encounter for open Other nondisplaced dens, initial encounter for Other nondisplaced dens, initial encounter for open Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for Page 9

10 S12.151b S12.190a S12.190b S12.191a S12.191b S12.200a S12.200b S12.201a S12.201b S12.230a S12.230b S12.231a S12.231b S12.24xa S12.24xb S12.250a S12.250b S12.251a S12.251b S12.290a S12.290b S12.291a S12.291b S12.300a S12.301a S12.330a S12.300b S12.301b S12.330b S12.331a Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open Other displaced of second cervical vertebra, initial encounter for Other displaced of second cervical vertebra, initial encounter for open Other nondisplaced of second cervical vertebra, initial encounter for Other nondisplaced of second cervical vertebra, initial encounter for open Unspecified displaced of third cervical vertebra, initial encounter for Unspecified displaced of third cervical vertebra, initial encounter for open Unspecified nondisplaced of third cervical vertebra, initial encounter for Unspecified nondisplaced of third cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open Other displaced of third cervical vertebra, initial encounter for Other displaced of third cervical vertebra, initial encounter for open Other nondisplaced of third cervical vertebra, initial encounter for Other nondisplaced of third cervical vertebra, initial encounter for open Unspecified displaced of fourth cervical vertebra, initial encounter for Unspecified nondisplaced of fourth cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for Unspecified displaced of fourth cervical vertebra, initial encounter for open Unspecified nondisplaced of fourth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for Page 10

11 S12.331b S12.34xa S12.34xb S12.350a S12.350b S12.351a S12.351b S12.390a S12.390b S12.391a S12.391b S12.400a S12.400b S12.401a S12.401b S12.430a S12.430b S12.431a S12.431b S12.44xa S12.44xb S12.450a S12.450b S12.451a S12.451b S12.490a S12.490b S12.491a S12.491b Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Other displaced of fourth cervical vertebra, initial encounter for Other displaced of fourth cervical vertebra, initial encounter for open Other nondisplaced of fourth cervical vertebra, initial encounter for Other nondisplaced of fourth cervical vertebra, initial encounter for open Unspecified displaced of fifth cervical vertebra, initial encounter for Unspecified displaced of fifth cervical vertebra, initial encounter for open Unspecified nondisplaced of fifth cervical vertebra, initial encounter for Unspecified nondisplaced of fifth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Other displaced of fifth cervical vertebra, initial encounter for Other displaced of fifth cervical vertebra, initial encounter for open Other nondisplaced of fifth cervical vertebra, initial encounter for Other nondisplaced of fifth cervical vertebra, initial encounter for open Page 11

12 S12.500a S12.500b S12.501a S12.501b S12.530a S12.530b S12.531a S12.531b S12.54xa S12.54xb S12.550a S12.550b S12.551a S12.551b S12.590a S12.590b S12.591a S12.591b S12.600a S12.600b S12.601a S12.601b S12.630a S12.630b S12.631a S12.631b S12.64xa S12.64xb S12.650a Unspecified displaced of sixth cervical vertebra, initial encounter for Unspecified displaced of sixth cervical vertebra, initial encounter for open Unspecified nondisplaced of sixth cervical vertebra, initial encounter for Unspecified nondisplaced of sixth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Other displaced of sixth cervical vertebra, initial encounter for Other displaced of sixth cervical vertebra, initial encounter for open Other nondisplaced of sixth cervical vertebra, initial encounter for Other nondisplaced of sixth cervical vertebra, initial encounter for open Unspecified displaced of seventh cervical vertebra, initial encounter for Unspecified displaced of seventh cervical vertebra, initial encounter for open Unspecified nondisplaced of seventh cervical vertebra, initial encounter for Unspecified nondisplaced of seventh cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed Page 12

13 S12.650b S12.651a S12.651b S12.690a S12.690b S12.691a S12.691b S12.9xxa S13.0xxa S13.100a S13.101a S13.110a S13.111a S13.120a S13.121a S13.130a S13.131a S13.140a S13.141a S13.150a S13.151a S13.160a S13.161a S13.170a S13.171a S13.180a S13.181a S13.20xa S13.29xa S22.000a S22.000b S22.001a S22.001b S22.002a S22.002b Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Other displaced of seventh cervical vertebra, initial encounter for Other displaced of seventh cervical vertebra, initial encounter for open Other nondisplaced of seventh cervical vertebra, initial encounter for Other nondisplaced of seventh cervical vertebra, initial encounter for open Fracture of neck, unspecified, initial encounter Traumatic rupture of cervical intervertebral disc, initial encounter Subluxation of unspecified cervical vertebrae, initial encounter Dislocation of unspecified cervical vertebrae, initial encounter Subluxation of C0/C1 cervical vertebrae, initial encounter Dislocation of C0/C1 cervical vertebrae, initial encounter Subluxation of C1/C2 cervical vertebrae, initial encounter Dislocation of C1/C2 cervical vertebrae, initial encounter Subluxation of C2/C3 cervical vertebrae, initial encounter Dislocation of C2/C3 cervical vertebrae, initial encounter Subluxation of C3/C4 cervical vertebrae, initial encounter Dislocation of C3/C4 cervical vertebrae, initial encounter Subluxation of C4/C5 cervical vertebrae, initial encounter Dislocation of C4/C5 cervical vertebrae, initial encounter Subluxation of C5/C6 cervical vertebrae, initial encounter Dislocation of C5/C6 cervical vertebrae, initial encounter Subluxation of C6/C7 cervical vertebrae, initial encounter Dislocation of C6/C7 cervical vertebrae, initial encounter Subluxation of C7/T1 cervical vertebrae, initial encounter Dislocation of C7/T1 cervical vertebrae, initial encounter Dislocation of unspecified parts of neck, initial encounter Dislocation of other parts of neck, initial encounter Wedge compression of unspecified thoracic vertebra, initial encounter for Wedge compression of unspecified thoracic vertebra, initial encounter for open Stable burst of unspecified thoracic vertebra, initial encounter for Stable burst of unspecified thoracic vertebra, initial encounter for open Unstable burst of unspecified thoracic vertebra, initial encounter for Unstable burst of unspecified thoracic vertebra, initial encounter for open Page 13

14 S22.008a S22.008b S22.009a S22.009b S22.010a S22.010b S22.011a S22.011b S22.012a S22.012b S22.018a S22.018b S22.019a S22.019b S22.020a S22.020b S22.021a S22.021b S22.022a S22.022b S22.028a S22.028b S22.029a S22.029b S22.030a S22.030b S22.031a S22.031b S22.032a S22.032b S22.038a S22.038b S22.039a S22.039b S22.040a S22.040b Other of unspecified thoracic vertebra, initial encounter for Other of unspecified thoracic vertebra, initial encounter for open Unspecified of unspecified thoracic vertebra, initial encounter for Unspecified of unspecified thoracic vertebra, initial encounter for open Wedge compression of first thoracic vertebra, initial encounter for Wedge compression of first thoracic vertebra, initial encounter for open Stable burst of first thoracic vertebra, initial encounter for Stable burst of first thoracic vertebra, initial encounter for open Unstable burst of first thoracic vertebra, initial encounter for Unstable burst of first thoracic vertebra, initial encounter for open Other of first thoracic vertebra, initial encounter for Other of first thoracic vertebra, initial encounter for open Unspecified of first thoracic vertebra, initial encounter for Unspecified of first thoracic vertebra, initial encounter for open Wedge compression of second thoracic vertebra, initial encounter for Wedge compression of second thoracic vertebra, initial encounter for open Stable burst of second thoracic vertebra, initial encounter for Stable burst of second thoracic vertebra, initial encounter for open Unstable burst of second thoracic vertebra, initial encounter for Unstable burst of second thoracic vertebra, initial encounter for open Other of second thoracic vertebra, initial encounter for Other of second thoracic vertebra, initial encounter for open Unspecified of second thoracic vertebra, initial encounter for Unspecified of second thoracic vertebra, initial encounter for open Wedge compression of third thoracic vertebra, initial encounter for Wedge compression of third thoracic vertebra, initial encounter for open Stable burst of third thoracic vertebra, initial encounter for Stable burst of third thoracic vertebra, initial encounter for open Unstable burst of third thoracic vertebra, initial encounter for Unstable burst of third thoracic vertebra, initial encounter for open Other of third thoracic vertebra, initial encounter for Other of third thoracic vertebra, initial encounter for open Unspecified of third thoracic vertebra, initial encounter for Unspecified of third thoracic vertebra, initial encounter for open Wedge compression of fourth thoracic vertebra, initial encounter for Wedge compression of fourth thoracic vertebra, initial encounter for open Page 14

15 S22.041a S22.041b S22.042a S22.042b S22.048a S22.048b S22.049a S22.049b S22.050a S22.050b S22.051a S22.051b S22.052a S22.052b S22.058a S22.058b S22.059a S22.059b S22.060a S22.060b S22.061a S22.061b S22.062a S22.062b S22.068a S22.068b S22.069a S22.069b S22.070a S22.070b S22.071a S22.071b S22.072a S22.072b S22.078a S22.078b Stable burst of fourth thoracic vertebra, initial encounter for Stable burst of fourth thoracic vertebra, initial encounter for open Unstable burst of fourth thoracic vertebra, initial encounter for Unstable burst of fourth thoracic vertebra, initial encounter for open Other of fourth thoracic vertebra, initial encounter for Other of fourth thoracic vertebra, initial encounter for open Unspecified of fourth thoracic vertebra, initial encounter for Unspecified of fourth thoracic vertebra, initial encounter for open Wedge compression of T5-T6 vertebra, initial encounter for Wedge compression of T5-T6 vertebra, initial encounter for open Stable burst of T5-T6 vertebra, initial encounter for Stable burst of T5-T6 vertebra, initial encounter for open Unstable burst of T5-T6 vertebra, initial encounter for Unstable burst of T5-T6 vertebra, initial encounter for open Other of T5-T6 vertebra, initial encounter for Other of T5-T6 vertebra, initial encounter for open Unspecified of T5-T6 vertebra, initial encounter for Unspecified of T5-T6 vertebra, initial encounter for open Wedge compression of T7-T8 vertebra, initial encounter for Wedge compression of T7-T8 vertebra, initial encounter for open Stable burst of T7-T8 vertebra, initial encounter for Stable burst of T7-T8 vertebra, initial encounter for open Unstable burst of T7-T8 vertebra, initial encounter for Unstable burst of T7-T8 vertebra, initial encounter for open Other of T7-T8 thoracic vertebra, initial encounter for Other of T7-T8 thoracic vertebra, initial encounter for open Unspecified of T7-T8 vertebra, initial encounter for Unspecified of T7-T8 vertebra, initial encounter for open Wedge compression of T9-T10 vertebra, initial encounter for Wedge compression of T9-T10 vertebra, initial encounter for open Stable burst of T9-T10 vertebra, initial encounter for Stable burst of T9-T10 vertebra, initial encounter for open Unstable burst of T9-T10 vertebra, initial encounter for Unstable burst of T9-T10 vertebra, initial encounter for open Other of T9-T10 vertebra, initial encounter for Other of T9-T10 vertebra, initial encounter for open Page 15

16 S22.079a S22.079b S22.080a S22.080b S22.081a S22.081b S22.082a S22.082b S22.088a S22.088b S22.089a S22.089b S23.0xxa S23.100a S23.101a S23.110a S23.111a S23.120a S23.121a S23.122a S23.123a S23.130a S23.131a S23.132a S23.133a S23.140a S23.141a S23.142a S23.143a S23.150a S23.151a S23.152a S23.153a S23.160a S23.161a S23.162a Unspecified of T9-T10 vertebra, initial encounter for Unspecified of T9-T10 vertebra, initial encounter for open Wedge compression of T11-T12 vertebra, initial encounter for Wedge compression of T11-T12 vertebra, initial encounter for open Stable burst of T11-T12 vertebra, initial encounter for Stable burst of T11-T12 vertebra, initial encounter for open Unstable burst of T11-T12 vertebra, initial encounter for Unstable burst of T11-T12 vertebra, initial encounter for open Other of T11-T12 vertebra, initial encounter for Other of T11-T12 vertebra, initial encounter for open Unspecified of T11-T12 vertebra, initial encounter for Unspecified of T11-T12 vertebra, initial encounter for open Traumatic rupture of thoracic intervertebral disc, initial encounter Subluxation of unspecified thoracic vertebra, initial encounter Dislocation of unspecified thoracic vertebra, initial encounter Subluxation of T1/T2 thoracic vertebra, initial encounter Dislocation of T1/T2 thoracic vertebra, initial encounter Subluxation of T2/T3 thoracic vertebra, initial encounter Dislocation of T2/T3 thoracic vertebra, initial encounter Subluxation of T3/T4 thoracic vertebra, initial encounter Dislocation of T3/T4 thoracic vertebra, initial encounter Subluxation of T4/T5 thoracic vertebra, initial encounter Dislocation of T4/T5 thoracic vertebra, initial encounter Subluxation of T5/T6 thoracic vertebra, initial encounter Dislocation of T5/T6 thoracic vertebra, initial encounter Subluxation of T6/T7 thoracic vertebra, initial encounter Dislocation of T6/T7 thoracic vertebra, initial encounter Subluxation of T7/T8 thoracic vertebra, initial encounter Dislocation of T7/T8 thoracic vertebra, initial encounter Subluxation of T8/T9 thoracic vertebra, initial encounter Dislocation of T8/T9 thoracic vertebra, initial encounter Subluxation of T9/T10 thoracic vertebra, initial encounter Dislocation of T9/T10 thoracic vertebra, initial encounter Subluxation of T10/T11 thoracic vertebra, initial encounter Dislocation of T10/T11 thoracic vertebra, initial encounter Subluxation of T11/T12 thoracic vertebra, initial encounter Page 16

17 S23.163a S23.170a S23.171a S23.20xa S23.29xa S32.000a S32.000b S32.001a S32.001b S32.002a S32.002b S32.008a S32.008b S32.009a S32.009b S32.010a S32.010b S32.011a S32.011b S32.012a S32.012b S32.018a S32.018b S32.019a S32.019b S32.020a S32.020b S32.021a S32.021b S32.022a S32.022b S32.028a S32.028b S32.029a S32.029b S32.030a Dislocation of T11/T12 thoracic vertebra, initial encounter Subluxation of T12/L1 thoracic vertebra, initial encounter Dislocation of T12/L1 thoracic vertebra, initial encounter Dislocation of unspecified part of thorax, initial encounter Dislocation of other parts of thorax, initial encounter Wedge compression of unspecified lumbar vertebra, initial encounter for Wedge compression of unspecified lumbar vertebra, initial encounter for open Stable burst of unspecified lumbar vertebra, initial encounter for Stable burst of unspecified lumbar vertebra, initial encounter for open Unstable burst of unspecified lumbar vertebra, initial encounter for Unstable burst of unspecified lumbar vertebra, initial encounter for open Other of unspecified lumbar vertebra, initial encounter for Other of unspecified lumbar vertebra, initial encounter for open Unspecified of unspecified lumbar vertebra, initial encounter for Unspecified of unspecified lumbar vertebra, initial encounter for open Wedge compression of first lumbar vertebra, initial encounter for Wedge compression of first lumbar vertebra, initial encounter for open Stable burst of first lumbar vertebra, initial encounter for Stable burst of first lumbar vertebra, initial encounter for open Unstable burst of first lumbar vertebra, initial encounter for Unstable burst of first lumbar vertebra, initial encounter for open Other of first lumbar vertebra, initial encounter for Other of first lumbar vertebra, initial encounter for open Unspecified of first lumbar vertebra, initial encounter for Unspecified of first lumbar vertebra, initial encounter for open Wedge compression of second lumbar vertebra, initial encounter for Wedge compression of second lumbar vertebra, initial encounter for open Stable burst of second lumbar vertebra, initial encounter for Stable burst of second lumbar vertebra, initial encounter for open Unstable burst of second lumbar vertebra, initial encounter for Unstable burst of second lumbar vertebra, initial encounter for open Other of second lumbar vertebra, initial encounter for Other of second lumbar vertebra, initial encounter for open Unspecified of second lumbar vertebra, initial encounter for Unspecified of second lumbar vertebra, initial encounter for open Wedge compression of third lumbar vertebra, initial encounter for Page 17

18 S32.030b S32.031a S32.031b S32.032a S32.032b S32.038a S32.038b S32.039a S32.039b S32.040a S32.040b S32.041a S32.041b S32.042a S32.042b S32.048a S32.048b S32.049a S32.049b S32.050a S32.050b S32.051a S32.051b S32.052a S32.052b S32.058a S32.058b S32.059a S32.059b S32.10xa S32.10xb S32.110a S32.110b S32.111a S32.111b S32.112a Wedge compression of third lumbar vertebra, initial encounter for open Stable burst of third lumbar vertebra, initial encounter for Stable burst of third lumbar vertebra, initial encounter for open Unstable burst of third lumbar vertebra, initial encounter for Unstable burst of third lumbar vertebra, initial encounter for open Other of third lumbar vertebra, initial encounter for Other of third lumbar vertebra, initial encounter for open Unspecified of third lumbar vertebra, initial encounter for Unspecified of third lumbar vertebra, initial encounter for open Wedge compression of fourth lumbar vertebra, initial encounter for Wedge compression of fourth lumbar vertebra, initial encounter for open Stable burst of fourth lumbar vertebra, initial encounter for Stable burst of fourth lumbar vertebra, initial encounter for open Unstable burst of fourth lumbar vertebra, initial encounter for Unstable burst of fourth lumbar vertebra, initial encounter for open Other of fourth lumbar vertebra, initial encounter for Other of fourth lumbar vertebra, initial encounter for open Unspecified of fourth lumbar vertebra, initial encounter for Unspecified of fourth lumbar vertebra, initial encounter for open Wedge compression of fifth lumbar vertebra, initial encounter for Wedge compression of fifth lumbar vertebra, initial encounter for open Stable burst of fifth lumbar vertebra, initial encounter for Stable burst of fifth lumbar vertebra, initial encounter for open Unstable burst of fifth lumbar vertebra, initial encounter for Unstable burst of fifth lumbar vertebra, initial encounter for open Other of fifth lumbar vertebra, initial encounter for Other of fifth lumbar vertebra, initial encounter for open Unspecified of fifth lumbar vertebra, initial encounter for Unspecified of fifth lumbar vertebra, initial encounter for open Unspecified of sacrum, initial encounter for Unspecified of sacrum, initial encounter for open Nondisplaced Zone I of sacrum, initial encounter for Nondisplaced Zone I of sacrum, initial encounter for open Minimally displaced Zone I of sacrum, initial encounter for Minimally displaced Zone I of sacrum, initial encounter for open Severely displaced Zone I of sacrum, initial encounter for Page 18

19 S32.112b S32.119a S32.119b S32.120a S32.120b S32.121a S32.121b S32.122a S32.122b S32.129a S32.129b S32.130a S32.130b S32.131a S32.131b S32.132a S32.132b S32.139a S32.139b S32.14xa S32.14xb S32.15xa S32.15xb S32.16xa S32.16xb S32.17xa S32.17xb S32.19xa S32.19xb S32.2xxa S32.2xxb S33.0xxa S33.100a S33.101a S33.110a S33.111a Severely displaced Zone I of sacrum, initial encounter for open Unspecified Zone I of sacrum, initial encounter for Unspecified Zone I of sacrum, initial encounter for open Nondisplaced Zone II of sacrum, initial encounter for Nondisplaced Zone II of sacrum, initial encounter for open Minimally displaced Zone II of sacrum, initial encounter for Minimally displaced Zone II of sacrum, initial encounter for open Severely displaced Zone II of sacrum, initial encounter for Severely displaced Zone II of sacrum, initial encounter for open Unspecified Zone II of sacrum, initial encounter for Unspecified Zone II of sacrum, initial encounter for open Nondisplaced Zone III of sacrum, initial encounter for Nondisplaced Zone III of sacrum, initial encounter for open Minimally displaced Zone III of sacrum, initial encounter for Minimally displaced Zone III of sacrum, initial encounter for open Severely displaced Zone III of sacrum, initial encounter for Severely displaced Zone III of sacrum, initial encounter for open Unspecified Zone III of sacrum, initial encounter for Unspecified Zone III of sacrum, initial encounter for open Type 1 of sacrum, initial encounter for Type 1 of sacrum, initial encounter for open Type 2 of sacrum, initial encounter for Type 2 of sacrum, initial encounter for open Type 3 of sacrum, initial encounter for Type 3 of sacrum, initial encounter for open Type 4 of sacrum, initial encounter for Type 4 of sacrum, initial encounter for open Other of sacrum, initial encounter for Other of sacrum, initial encounter for open Fracture of coccyx, initial encounter for Fracture of coccyx, initial encounter for open Traumatic rupture of lumbar intervertebral disc, initial encounter Subluxation of unspecified lumbar vertebra, initial encounter Dislocation of unspecified lumbar vertebra, initial encounter Subluxation of L1/L2 lumbar vertebra, initial encounter Dislocation of L1/L2 lumbar vertebra, initial encounter Page 19

20 S33.120a S33.121a S33.130a S33.131a S33.140a S33.141a S33.2xxa S33.39xa Subluxation of L2/L3 lumbar vertebra, initial encounter Dislocation of L2/L3 lumbar vertebra, initial encounter Subluxation of L3/L4 lumbar vertebra, initial encounter Dislocation of L3/L4 lumbar vertebra, initial encounter Subluxation of L4/L5 lumbar vertebra, initial encounter Dislocation of L4/L5 lumbar vertebra, initial encounter Dislocation of sacroiliac and sacrococcygeal joint, initial encounter Dislocation of other parts of lumbar spine and pelvis, initial encounter *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. X. POLICY HISTORY CAC 1/28/03 CAC 1/25/05 CAC 2/28/06 Consensus CAC 2/27/07 CAC 11/27/07 CAC 1/27/09 CAC 1/26/10 Consensus CAC 4/26/11 Minor revision. A policy statement was added that spinal manipulation and manipulation of other joints under anesthesia involving serial treatment sessions is considered investigational. A policy statement was also added that manipulation under anesthesia involving multiple body joints is considered investigational for treatment of chronic pain. CAC 8/28/12 Adopting BCBSA for the following changes. Use of manipulation under anesthesia for treatment of arthrofibrosis of the knee ROM limitation of <90 degrees was deleted. Added MN statement for use in treatment of long bone s or dislocations. Previously limited to vertebral s Added investigational statement on use for manipulation with patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain. Also, added note Manipulation under anesthesia (MUA) of the shoulder or knee should be attempted only after an adequate trial of conservative measures (physical Page 20

21 therapy and joint injections) have failed to restore range of motion and relieve pain for further clarification of policy statement. Added FEP variation to reference FEP Medical Policy Manual MP Manipulation Under Anesthesia for Treatment of Chronic Spinal or Pelvic Pain 04/08/13- Admin code review CAC 7/30/13 Consensus review. References updated but no changes to the policy statements. CAC 3/25/14 Consensus review. References updated but no changes to the policy statements. Rationale added. No coding changes. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 21