Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

Spinal Manipulation Under General Anesthesia

Description:

Manipulation Under Anesthesia

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion (Kohlbeck, 2002). 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 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 spine, when standard care, including manipulation, and other conservative measures have failed. 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 led to decreased use of the procedure in favor of other therapies. Manipulation under anesthesia was modified and revived in the 1990s. This revival has been attributed to increased interest in spinal manipulative therapy and the advent of safer, shorter-acting anesthesia agents used for conscious sedation.

Manipulation Under Anesthesia Administration

Manipulation under anesthesia of the spine is described as follows: after sedation, a series of mobilization, stretching, and traction procedures to the spine and lower extremities are 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 (Kohlbeck, 2002). After the stretching and traction procedures, spinal manipulative therapy is delivered with high-velocity, short-amplitude thrust applied to a spinous process by hand, while the upper torso and lower extremities are stabilized. Spinal manipulative therapy may also be applied to the thoracolumbar or cervical area when necessary to address 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 3 or more consecutive days for best results. Care after manipulation under anesthesia may include 4 to 8 weeks of active rehabilitation with manual therapy, including spinal manipulative therapy and other modalities. Manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal (facet) and/or sacroiliac joints under fluoroscopic guidance (manipulation under joint anesthesia/analgesia) and after epidural injection of corticosteroid and local anesthetic (manipulation post-epidural injection). Spinal manipulation under anesthesia has also been combined with other joint manipulation during multiple sessions. Together, these therapies may be referred to as medicine-assisted manipulation.

This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and /or fibrosis of a joint that may occur following total joint replacement.

Coding

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:

Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria

Spinal Manipulation Under General Anesthesia does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.

For members with contracts without primary coverage criteria, Spinal Manipulation Under General Anesthesia is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.

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.

2019 Update

A literature search was conducted through August 2019. There was no new information identified that would prompt a change in the coverage statement.

2020 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2020. No new literature was identified that would prompt a change in the coverage statement.

2021 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2021. No new literature was identified that would prompt a change in the coverage statement.

2022 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2022. No new literature was identified that would prompt a change in the coverage statement.

2023 Update

Annual policy review completed with a literature search using the MEDLINE database through August 2023. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:

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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