Coverage Policy Manual
Policy #: 2001003
Category: Surgery
Initiated: August 2017
Last Review: September 2018
  Spinal Manipulation Under General Anesthesia

Description: In the appendicular skeleton, manipulation with the patient under anesthesia (MUA) may be performed as a treatment of arthrofibrosis, particularly of the shoulder (i.e., frozen shoulder) or knee. In the spine, manipulation under anesthesia may be performed as a closed treatment of vertebral fracture or dislocation. This policy does not address the treatment of vertebral fractures or dislocations. In the absence of vertebral fracture or dislocation, MUA, performed either with the patient sedated or under general anesthesia, may be performed as a treatment of subluxation and is intended to overcome the conscious patient's protective reflex mechanism, which may limit the success of prior attempts of spinal manipulation or adjustment in the conscious patient. In MUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical spinal adjustment. A single session of MUA may be offered, followed by a series of outpatient sessions, or a series of up to 5 sessions of MUA may be offered, also followed by outpatient sessions. In some instances the MUA may be accompanied by corticosteroid injections.

CPT 22505 is the correct code for billing for spinal manipulation requiring anesthesia.  CPT Assistant, March 1997, has the following comment regarding this code: "From a CPT coding perspective, code 22505 should be reported only once, for any and all regions manipulated on that date. The  definition of the code, according to CPT Assistant, Volume 9, Jan 99, page 11, states that this code requires the patient to receive general anesthesia.

In the past, assistant surgeon has been billed for this procedure.  Assistant surgeon would not be allowed.  The American College of Surgeons list CPT as category "3" on the ACS Assistant Surgeon list (seldom required).

Policy/
Coverage:
Spinal Manipulation Under General Anesthesia does not meet Primary Coverage Criteria that there be scientific evidence of effectiveness and is not covered.

For contracts without Primary Coverage Criteria, Spinal Manipulation Under General Anesthesia is considered investigational.  Investigational services are an exclusion in the member benefit certificate.

Rationale:
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. A search of the published medical literature did not identify any controlled clinical trials. Several case series were identified, which included patients with cervical, thoracic, and lumbar back pain, treated according to varying protocols. In the largest case series, West and colleagues reported on 177 patients with back pain who had failed prior therapy. The patients were treated with 3 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 VAS scores. However, this uncontrolled study cannot isolate the contribution of the 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 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 MUA compared to a 26% decrease in those receiving conventional treatment. The lack of a true control group limits interpretation of this study. Other small case series focused on the use of manipulation in conjunction with corticosteroid injections.  Similarly, this literature does not permit scientific interpretation.
 
Chiropractic Guidelines
Chiropractic guidelines, referred to as the Mercy Center Consensus Conference, were first issued in 1993 and reaffirmed in 1999.  This guideline development process was sponsored by several organizations —Congress of Chiropractic State Associations, American Chiropractic Association, Canadian Chiropractic Association, International Chiropractic Association, Federation of Chiropractic Licensing Boards, and the Foundation for Chiropractic Education and Research. These guidelines gave manipulation under anesthesia an "equivocal" rating, defined as a technology in which "current knowledge exists to support a given indication in a specified patient population, though value can neither be confirmed nor denied."
 
2009 Update
A search of the Medline database for the period of August 2005 through Febraury 2009 did not identify any published literature that would warrant a change in the coverage policy statement.
 
2012 Update
This policy is being updated with a literature review of the MEDLINE database. The review did not yield any new publications that would prompt a change in the coverage statement. Scientific evidence regarding spinal manipulation under anesthesia is limited to observational case series and nonrandomized comparative studies. Evidence is insufficient to determine whether MUA improves health outcomes. The policy is unchanged.
 
2016 Update
A literature search conducted through August 2016 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through August 2017 did not reveal any new information that would prompt a change in the coverage statement.
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2018. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
00640Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine
01999Unlisted anesthesia procedure(s)
22505Manipulation of spine requiring anesthesia, any region

References: Aspegren DD, Wright RE, Hemler DE.(1997) Manipulation under epidural anesthesia with corticosteroid injection: two case reports. J Manipulative Physiol Ther 1997; 20(9):618-21.

Ben-David B, Raboy M.(1994) Manipulation under anesthesia combined with epidural steroid injection. J Manipulative Physiol Ther 1994; 17(9):605-9.

Haldeman S, Chapman-Smith D, Petersen DM (eds), et al.(1992) Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference; Burlingame, CA, January 25-30. Aspen Publishers 1992.

Haldeman S, et al.(1999) Proceedings of the Mercy Center Consensus Conference. Guidelines for Chiropractic Quality Assurance and Practice Parameters; Aspen Publishers 1999.

Herzog J.(1999) Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome. J Manipulative Physiol Ther 1999; 22:166-70.

Kohlbeck FJ, Haldeman S.(2002) Medication-assisted spinal manipulation. Spine J; Jul-Aug 2002; 2(4):288-302.

Michaelsen MR.(2000) Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal asis pain of synovial joint origin. J Manipulative Physiol Ther 2000; Feb;23(2):127-9.

Palmieri NF, Smoyak S.(2002) Chronic low back pain: A study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25:E8-17.

Palmieri NF, Smoyak S.(2002) Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther Oct 2002; 25(8):E8-E17.

West DT, Mathews RS, Miller MR, et al.(1999) 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.

West DT, Mathews RS, Miller MR, et al.(1999) Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999; 22:299-308.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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