CG-MED-65 Manipulation Under Anesthesia

This document addresses the use of manipulation under anesthesia of the spine. This document also addresses the use of manipulation under anesthesia of joints other than the knee and shoulder. Anesthesia types may include local, regional, intravenous (IV) monitored sedation, and general.

Note: Please see the following related documents for additional information:

Manipulation under anesthesia of the spine is considered medically necessary for the treatment of vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine.

Manipulation under anesthesia of the spine is considered not medically necessary for all other diagnoses not listed above.

Manipulation under anesthesia of any other joint not listed above as medically necessary, except for the knee or shoulder, is considered not medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Not Medically Necessary:
For the procedure code listed above for all other diagnoses not listed.

Other joints (excluding knee and shoulder)
When services are Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Manipulation refers to the use of a variety of manual techniques to adjust the spinal column and joints, improve the range of motion of the joints, stretch and relax connective tissue and muscles, and promote overall relaxation. It can be used in conjunction with anesthesia. With anesthesia, the individual is less apprehensive and the anesthesia allows for reduced muscle tone and protective reflex mechanisms.

Spine
Manipulation under anesthesia of the spine has been proposed as a treatment modality for spinal dysfunction. This procedure is typically performed in one single session. Some chiropractors, with the assistance of anesthesiologists, have also employed this technique to alleviate acute and chronic neck and back pain.

Manipulation under anesthesia of the spine is considered an established treatment option for vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine and will not be discussed further. Therefore, this discussion will focus on manipulation under anesthesia of the spine as a treatment of chronic back pain, other musculoskeletal disorders and the pain associated with incomplete dislocation.

As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. In a case series, West and colleagues (1999) reported on 177 individuals with acute and chronic back pain who had failed prior therapy. The individuals were treated with three sequential manipulations under intravenous sedation, followed by 4 to 6 weeks of further chiropractic spinal manipulation. At the 6-month follow-up, there was a 60% improvement in visual analog scale scores. However, this uncontrolled study cannot isolate the contribution of the spinal manipulation under anesthesia; treatment effect could also be related to the placebo effect, the effect of continued chiropractic therapy, or the natural history of the condition.

Palmieri and Smoyak (2002) evaluated the efficacy of manipulation under anesthesia using a self-reported pain questionnaire in a convenience sample of those undergoing spinal manipulation compared to conventional chiropractic treatment. The pain scales decreased by 50% in those treated with spinal manipulation under anesthesia compared to a 26% decrease in those receiving conventional treatment. The lack of a true control group limits interpretation of this study. Similarly, this literature does not permit scientific interpretation.

In a prospective cohort study of 68 individuals with chronic low back pain, Kohlbeck and colleagues (2005) measured changes in pain and disability for those with low back pain who received spinal manipulation with intravenous analgesia and sedation and compared these to changes in a group only receiving spinal manipulation. Individuals with pain caused by a fracture were excluded. All individuals received an initial 4- to 6-week trial of spinal manipulation, after which 42 individuals received supplemental spinal manipulation under anesthesia and the remaining 26 individuals continued with spinal manipulation without anesthesia. Low back pain and disability measures favored the spinal manipulation under anesthesia group over the spinal manipulation only group at 3 months. This difference narrowed at 1 year. The investigators concluded spinal manipulation under anesthesia appears to offer some improvement in low back pain and disability. However, the investigators noted, “improvements may not endure,” and “the clinical changes observed are not necessarily caused by SMUA and large randomized controlled trials are necessary to determine effectiveness.”

In 2014, Peterson and colleagues reported on 30 individuals with chronic neck pain (n=13) or chronic back pain (n=17) who after receiving conservative therapy without relief had a single session of manipulation under anesthesia. Pain was assessed using a numeric rating scale (NRS) and the Bournemouth Questionnaire (BQ) at 2 weeks and at 1 day prior to manipulation under anesthesia. At 2 weeks and 4 weeks following the manipulation under anesthesia, the Patient's Global Impression of Change (PGIC) (primary outcome measure), the NRS for low back pain/neck pain and the BQ were collected by telephone interview. At the 2 week assessment, 52% of participants reported clinically relevant improvement with 45.5% of participants reporting improvement after 4 weeks. In this study, improvement was defined as responses of much better or better on the PGIC scale. No adverse events from the manipulation under anesthesia were reported. While participants reported improvement at 4 weeks following manipulation under anesthesia, further studies are required with long term outcomes to effectively evaluate efficacy of manipulation under anesthesia for chronic neck or back pain.

Manipulation under anesthesia of the spine may be performed in two general settings; for example, as a closed treatment of vertebral fracture or complete dislocation, or as a form of treatment of the pain associated with incomplete dislocation, that is, subluxation. In the latter setting, spinal manipulation or adjustment under anesthesia is intended to overcome the conscious individual’s protective reflex mechanisms, which may limit the success of spinal manipulation in the conscious individual. While general anesthesia is typically used for the closed treatment of vertebral fracture or complete dislocations, spinal manipulation for the treatment of incomplete dislocations typically uses either conscious sedation or regional anesthesia. A low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique used in the typical spinal adjustment in the conscious individual.

At this time, evidence from the available peer-reviewed literature does not support manipulation under anesthesia of the spine in the absence of vertebral fracture, complete dislocation, or acute traumatic incomplete dislocation (subluxation) as a treatment for pain that is in accordance with generally accepted standards of medical practice.

Other Joints
Manipulation under anesthesia has also been suggested as a treatment for conditions of other joints such as the elbow, wrist, hand, finger, pelvis and ankle. Current peer-reviewed literature includes retrospective chart reviews and single case series. There are no controlled studies or any studies reporting long-term follow-up with outcomes. At this time there is insufficient evidence in peer-reviewed medical literature to establish and support the use of manipulation under anesthesia for other joints such as the elbow, wrist, hand, finger, pelvis and ankle as treatment that is in accordance with generally accepted standards of medical practice.

Dislocation: The displacement of a bone from its normal position, which can be classified as either complete or incomplete. This distinction may be made with imaging studies.

Subluxation: A condition in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. This is also known as a partial or incomplete dislocation.

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Subject: Manipulation Under Anesthesia
Guideline #: CG-MED-65	Publish Date: 09/27/2023
Status: Reviewed	Last Review Date: 08/10/2023

CPT
22505	Manipulation of the spine requiring anesthesia, any region

ICD-10 Diagnosis
S12.000A-S12.691S	Fracture of cervical vertebra
S13.100A-S13.4XXS	Subluxation and dislocation of cervical vertebrae and neck
S22.000A-S22.089S	Fracture of thoracic vertebra
S23.100A-S23.171S	Subluxation and dislocation of thoracic vertebra
S32.000A-S32.2XXS	Fracture of lumbar vertebra, sacrum, coccyx
S33.100A-S33.39XS	Subluxation and dislocation of lumbar vertebra, sacroiliac and sacrococcygeal joint

CPT
24300	Manipulation, elbow, under anesthesia
25259	Manipulation, wrist, under anesthesia
26340	Manipulation, finger joint, under anesthesia, each joint
27275	Manipulation, hip joint, requiring general anesthesia
27860	Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

ICD-10 Diagnosis
	All diagnoses

Status	Date	Action
Reviewed	08/10/2023	Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information section.
Reviewed	08/11/2022	MPTAC review. Updated Description and Discussion/General Information sections.
Reviewed	08/12/2021	MPTAC review. Updated Discussion/General Information section.
Reviewed	08/13/2020	MPTAC review. Updated Discussion/General Information section. Reformatted Coding section.
Reviewed	08/22/2019	MPTAC review. Updated Description section.
Revised	11/08/2018	MPTAC review. Document updated to remove shoulder from the scope. Clinical indications edited to remove shoulder. Title changed. Updated Coding, Description, Discussion/General Information, Definitions, References, and Index sections.
New	11/02/2017	MPTAC review. Initial document development. Moved content of MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee to new clinical utilization management guideline document with the same title.