Manipulation of the Knee and Manipulation of the Shoulder 

• Knee (Procedure Code 27570)
  Manipulation of the knee under anesthesia  is eligible when performed to treat significant arthrofibrosis of the knee resulting from trauma or knee surgery.
  
  
• Shoulder (Procedure Code 23700)
  Manipulation of the shoulder under anesthesia is eligible when performed to treat capsulitis of the shoulder.

Manipulation of the knee and shoulder will be denied as not medically necessary when reported for any other conditions. 

Manipulation under anesthesia (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. 

MUA is limited to a single treatment session. Serial manipulations of a joint  are not medically necessary. When procedure code 27570 or 23700 is reported two or three days in succession, the first service will pay when reported with an eligible condition. The remaining services will deny as not medically necessary. 

All associated services, such as anesthesia and facility expenses, will also be denied as not medically necessary.
               
Documentation Requirements

The medical record should include the following documentation:

• Failure of condition to respond to conservative therapy, i.e., physical therapy and joint injections;
• Evidence of decreased range of motion; and,
• Length of time that the patient has been symptomatic.

Ankle, Elbow, Finger, Hip, Pelvic Ring, Spine, and Wrist 

Manipulation under anesthesia of the following joints will be denied as not medically necessary: ankle (27860), elbow (24300), finger (26340), hip (27275), pelvic ring (27194), spine (22505) and wrist (25259). 

Services that do not meet the medical necessity guidelines on this policy, including eligible conditions and frequency guidelines, will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

For information concerning manipulation of the temporomandibular joint under anesthesia, see Medical Policy Bulletin V-23.  

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

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