The Whole Truth About Manipulation Under Anesthesia (MUA)

It has been some time since I have addressed this topic in this publication. Part of the reason is that I have been completing a textbook on MUA, and the other reason is that there have been many changes as far as written material and protocols with regard to the MUA procedures. These changes have come about because MUA has taken on new interest in the field of both chiropractic and osteopathy in the last few years, and in the field of pain management in general.

I have mentioned previously that MUA will continue to be a very productive alternative in the field of pain management and that despite the arguments that the insurance carriers continue to mount against MUA, it is here to stay. The purpose of this article is to present information as a rebuttal to what the insurance world has been trying to do: convince the health care arena that MUA is investigational or experimental, and therefore should not be reimbursable. This is such a tired, old argument that it is hardly worth the time to discuss. But because it is constantly referred to in the denials that some of the more prominent insurance carriers use, it is time to address these concerns.

There are several points that seem to constantly be used by insurance carriers to deny claims for manipulation under anesthesia, or what is now commonly referred to as fibrosis release procedures using medication-assisted manipulation with monitored anesthesia care (MAC). We use this terminology to better describe what is actually occurring during the procedure, which is listed in the AMA CPT codebook of reimbursable procedures as 22505, "manipulation of the spine requiring anesthesia, any area," considered a category 1 CPT coded procedure. The points or arguments that I would like to address regarding this procedure are the following:

1. Is MUA an experimental/investigational procedure? In Frank Kohlbeck and Scott Haldeman's 2002 article in The Spine Journal,¹ they state that the MUA procedure has been used for more than 70 years. They mention that much of the review of the literature indicates that anecdotal information is more prevalent than true randomized controlled studies, and that the field of medication-assisted manipulation needs more investigation. I believe that this is very true, and that they are absolutely right. But the statement, made by two prominent researchers, is being misrepresented. What was said was that more investigation was necessary, just like any procedure should be continuously researched; and that as with any good procedure, as more research is accomplished, more is understood about what is occurring, when the results have been as dramatic as the results using the MUA technique. They did not say the procedure is investigational or experimental. More investigation into a procedure for a better understanding of outcomes is not the same as an investigational procedure that has no historical track record. Even though much of the clinical record for the MUA procedure has been passed down in clinical case-study form, there is considerable historical evidence of positive patient response.

What is an experimental procedure, and when does it become acceptable in the health care arena as a non-experimental procedure? This is very easily addressed in the AMA CPT codebook of reimbursable procedures, in the introduction to that publication.² In order for a procedure to be included in the AMA CPT codebook of reimbursable procedures, it must first have undergone clinical validation by being used by same or similar practitioners for the same or similar conditions. It must then go through the review process by an 11-member panel that evaluates the outcomes of the procedure used by same or similar practitioners; the review panel then makes a recommendation that the procedure be included within the proper section of the codebook. This is then part of a recommendation review for publication in the codebook, and the procedure does not appear in this book unless it passes all of these reviews and evaluations.

According to an April 2004 letter from the AMA regarding CPT code 22505, in response to Dr. Daniel West's (an advisory member of the National Academy of MUA Physicians) request for clarification of this procedure, the following is required of the CPT Advisory Committees and the CPT Editorial Panel for CPT publication as a category 1 procedure (which is what 22505 is listed as):

Apparently, the MUA procedure passed all of the required reviews, because it has a CPT code. That code, 22505, is listed in an area of the CPT codebook that describes procedures involving the spine and the use of an anesthesia with the spine. The book does not indicate that the procedure is used with any specific kind or type of anesthesia, but describes "manipulation of the spine requiring anesthesia, any area." It also is described as manipulation of the spine. It does not relate to mobilizing the spine after fracture or dislocation; it specifically relates to "manipulation." The codes that are used above this code in the CPT code-book specifically describe fracture of the spine methods, which may or may not involve manipulation while "setting or relocating" fractured spinal segments.

CPT code 22505 was placed in this codebook when the procedure was more prominent in the osteopathic and orthopedic arenas. It was used to describe more advanced mobilizing, manipulating, and adjusting of the spine and surrounding holding elements while the patient is under the influence of anesthesia. Today, the more skilled practitioners in the chiropractic and osteopathic professions, using this technique more frequently and with the more advanced forms of anesthesia, are better able to accomplish what we want to accomplish by using MAC (monitored anesthesia care). This does not change the fact that this is the proper code for this procedure. CPT code 22505 is used as a category 1 code in this codebook of reimbursable procedures and is therefore not an investigational or experimental procedure.2 This question of experimental/investigational concerns has been brought before the CPT codebook review panel; it related that the code is listed as a category 1 code and as such, has had the proper follow-up in clinical justification and therefore, as stated above, is not considered experimental.

2. Is MUA a logical medical alternative in the normal progression of health care delivery for neuromusculoskeletal pain and/or injury? Despite what some would think, both in the chiropractic arena and the medical arena, MUA has taken its rightful place in the natural regime of pain management. In most of the cases that have been completed, the patients have chronic, recurrent neuromusculoskeletal problems that have been under care in various forms for an average of two to three months. Most cases have already undergone injection therapy. Most have exhausted manual therapy regimes with minimal results, at best. Many have been surgical failures, even with a minimally invasive procedure. And most have had comprehensive diagnostic workups that have been indecisive in terms of the etiology of the patient's complaint. MUA patients experience true "last resort" propensities because other therapies have just not worked. Remember, MUA cases are selected based on specific parameters, one of which is response to manual therapy, even if only minimal.

3. Has enough research in this field been completed to justify its use as compared to other more prominent procedures that are used and reimbursed routinely (e.g., intradiscal electrothermal therapy [IDET], minimally invasive disc surgery), but like MUA, still need more research? There is never "enough" research for prominent treatment modalities, and the continuously expanding volume of knowledge about procedures is always at the core of practical everyday use. But the use of modalities that are showing successful results should not be hampered by unfounded, biased or antiquated opinions based on a particular person, company or group that has not taken the time to fully investigate outcomes. Again, I quote from the literature review completed for the North American Spine Society's The Spine Journal, wherein Kohlbeck and Haldeman state:

"If a clinician recommends or offers, and a payor reimburses, surgery, injections, epidurals and certain physical therapy approaches to patients without requiring substantial proof of the effectiveness and safety, then it would be difficult to deny the use of medication-assisted manipulation or fail to reimburse for it."¹

This article is constantly quoted by insurance carriers in piecemeal fashion to help deny claims for MUA, even though the context of the article was not completely used. The authors continue on as a conclusion for their review by stating: "If on the other hand a clinician or payor rejects all surgery that does not have a body of controlled clinical trials supporting its use and refuses to offer patients or pay for most injection and physical therapy procedures that have limited or no research support, then it would be reasonable to reject medication-assisted manipulation until such research is carried out and published." This certainly would be the case if all of the modalities that are used to treat the general public today were put under the same scrutiny. However, the authors conclude that since this is not the case: "It would seem unreasonable to hold medication-assisted manipulation to a higher standard of scientific rigor than that required of other treatment approaches."¹

4. What is the focus of the future of this procedure and how will it become more mainstream in the health care delivery field, especially in the field of pain management, in the next few years? Every year, hundreds of cases are being treated by using this modality. As has been customary in the past, much of what is being accomplished is being lost to clinical record instead of documentary research. It is hoped that this is changing rapidly with the advent of new research trends, and with the countless number of patients responding so well to this modality, the future of MUA has to be in the decisive documentation that will be recorded in our scientific journals. But in the same context, continued use of MUA is the only way we will see the validity of this procedure. And just like other modalities that have been standards of care for so many years, MUA will take its rightful place alongside these treatment options, not because it is a new fad or a billable procedure that generates additional revenue, but because it improves the lives of countless patients with conditions that respond best to the procedure.

References

1. Kohlbeck F, Haldeman S. Medication-assisted spinal manipulation. The Spine Journal 2002: 288-302.
2. AMA CPT codebook.
3. Letter from the AMA CPT Code Panel to Dr. Daniel West, April 2004.

Robert C. Gordon, DC, DAAPM
Salisbury, North Carolina