From a clinical standpoint, MUA has never been questioned as an alternative to correcting fixated articulation, and shortened muscles. But, as a procedure performed by the chiropractic profession, it is questioned constantly.
Manipulation Under Anesthesia or medication-assisted manipulation has long been used by the orthopedic, and osteopathic professions to correct joint fixation. Chiropractic physicians started using this technique in the late 80’s as an alternative to chronic fixation syndromes, which were allowing only minimally responsive results in the office environment. Instead of losing the patient to other more invasive types of care, those chiropractic physicians who became certified in the MUA procedure now had an alternative to offer patients.
As time has progressed, more and more of these procedures have been completed by chiropractic physicians. In response to this increase, the chiropractic profession has taken more and more abuse from the insurance industry concerning “medical necessity”; “the experimental and investigational” nature of MUA; “the proper use of surgery centers and chiropractic”; “whether the procedure is to be done under intravenous sedation, or is done under a general anesthesia”; (here’s a good one), “that the MUA procedure has a higher morbidity rate than general surgery”; and a multitude of other excuses not to have to pay for this procedure.
In the meantime, hundreds of patients owe their lives and the return of their everyday lifestyles to MUA and the certified practitioners who diligently work to make this procedure a legitimate and credible procedure in the field of pain management. I am the first to admit that there are doctors and facilities out there that are making that very difficult by abusing the system and charging outrageous fees for this procedure. But far and above this abuse are the quality doctors out there who are trying to make this procedure a good procedure for properly selected patients, using established standards and protocols.
This article is written at a time when the insurance carriers of the United States are gathering what they hope will be enough documentation to eliminate medication-assisted manipulation from the health care delivery environment. In order to do this, they have convinced several regulatory agencies in the United States, such as the American College of Occupational and Environmental medicine (ACOEM) in California and the Dept. of Insurance and Banking in New Jersey, that MUA carries no clinical basis for the results that we are achieving everyday in this field. Shamefully, to do that, they use misinterpreted information, antiquated documentation, and the “controlled trial” rhetoric as a smoke screen to try to prevent the actual patient outcome information that is being achieved everyday in hospitals and ambulatory surgical centers, using this technique, from being disseminated to the proper sources so that denials can be made and “justified”. Fortunately, there is now a textbook on MUA that is progressively filtering throughout the United States that will ultimately give MUA the credibility that it has needed for many years and stop this unjust opinionated uninformed nonsense from continuing.
This paper is specifically written to give clinical credence to the MUA technique, and the concepts that we are expressing are directly from the textbook, Manipulation Under Anesthesia, Concepts In Theory and Application, Taylor and Francis, April 2005.
To make this fit into the allowable content of this article, I will relate more generally to our scientific concepts rather than delving into minute details. I will allow the reader to, instead, refer to the textbook, for continued reference.
For decades, manipulation under anesthesia, whether completed with IV sedation, general anesthesia, or local anesthesia, has been used by physicians to move fixated articulations and stretch shortened muscles.1,2,3,4,5 It has been the therapy of choice for hundreds of orthopedic surgeons, osteopathic physicians and chiropractic physicians over the past 70 years, and it has been the therapy of choice because it works.
Dr. Rob Francis relates to the changes that occur during MUA in chapter 2, pages 13-23, in the above referenced textbook as “restoring biomechanical integrity to areas of articular dyskinesia due to pathomechanical factors, including loss of joint mobility, fibroblastic proliferative changes of the supporting soft tissue resulting in decreased or lost flexibility/viscoelasticity, and neurological and vascular changes resulting from articular dyskinesia.”6 Now, that may sound foreign to some insurance carriers, but that describes almost all of the cases of fixation syndromes that they have been paying claims for over the years for various types of practitioners, including chiropractic, osteopathy, and physical medicine.
The only difference is that we are introducing medication-assisted manipulation to the equation. The difference in what has been paid by insurance carriers in the past and what we are requesting today is a comfort level for patients with chronic pain. As an example, when a patient goes into the emergency room for stitches, an anesthesia is used to block the painful stimulus of the needle stitching the laceration. That is exactly what we are now incorporating into the field of manual therapy today—patient comfort. Nothing is foreign, nothing is new, nothing is experimental; the procedures that we are using are all tried and true; the anesthesia that is used has been used hundreds and thousands of times with the same or similar procedures; and the practitioners are all experienced adjustors/manipulative therapists.
The problem that we are facing is a fee schedule, and the type of provider that is performing the procedure. If this were not true, then why has this not been an issue for the years this procedure has been used by other practitioners besides the chiropractic physician. CPT code 22505 is listed in the CPT codebook of reimbursable procedures as a category 1 type procedure. The procedure has had a CPT code for more than 20 years. Why is it, then, that in the last 10 years, since the chiropractic profession started using the procedure, it is considered “experimental,” or lacking the “control randomized” studies? Why is it that other professionals can bill for this procedure and receive immediate reimbursement, and the chiropractic physician must submit documentation after documentation to “justify” the use of the procedure? It’s the same procedure that the other professionals are using, except we are more skilled in manual therapy than any of these other professionals.
From a clinical standpoint, MUA has never been questioned as an alternative to correcting fixated articulation, and shortened muscles. But, as a procedure performed by the chiropractic profession, it is questioned constantly. Why is that?! Why is it that the chiropractic profession continues diligently to research this procedure, and document the results we get, and yet nothing we do seems good enough to have the insurance companies and their regulatory agencies stop harassing us?! Do we stop providing this very beneficial procedure? Or do we continue to show these carriers and agencies that they are wrong?
Yes, this is controversial. I expect it will continue to be controversial until insurance carriers and regulatory agencies realize that we are not going to go away. We will continue to fight for the rights of our patients to receive what has, ultimately, become one of the better forms of pain management, even if our carriers don’t want to accept what we are doing.
There are two very real reasons why I continue to believe that this procedure will ultimately win this war. First is the reaction of the doctors when they see how their patients respond to the procedure. And second is the documented astonishing results the patients achieve after suffering from pain for months and sometimes even years. With these results constantly being achieved, I, personally, will not stop fighting until we finally make these people realize that MUA is a real, viable alternative to chronic conservative care or potential preventable surgical intervention.
1. Clemente CD. Gray’s Anatomy. Thirtieth American Edition. Philadelphia: Lea & Febiger, 1985.
2. Davis, DGm Manipulation of the Lower Extremity. In Subotnick, SI (ed.) Sports Medicine of the Lower Extremity. London: Churchill-Livingstone, 1989.
3. Travell, J and Simons, D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, 1992.
4. Cox JM. Low Back Pain Mechanism, Diagnosis and Treatment. Fifth edition. Baltimore: Williams & Wilkins, 1990.
5. Steiner C, Staubs C, Ganon M, Buhlinger CD. Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc 1987; 87:318-22.
6. Fuhr, A et al. Activator Methods Chiropractic Technique. Mosby-Year Book, Inc, 1997.
Dr. Gordon's Comments on MUA Under Fire
TAC: Dr. Gordon, what is your definition of Manipulation Under Anesthesia?
Gordon: Manipulation Under Anesthesia is a medication-assisted form of manipulation that provides the ability to stretch and restore muscles that have been in disuse as a result of injury and/or chronic joint dysfunction. It is an extremely valuable technique that many chiropractors are now adding to their practice as another option for helping chronic pain patients.
TAC: Is MUA a chiropractic procedure?
Gordon: Not solely. Despite the accusations of some insurance carriers, MUA is a procedure that uses the very skilled services of the chiropractic physician, but via a team approach. It takes medical clearance, an anesthesiologist, the certified attending doctor, the certified co-attending doctor, and the nursing staff to run MUA procedures successfully.
TAC: The issue of practicing medicine without a license has now come up with regard to chiropractors performing MUA in California. Perhaps you can shed some light on what may be going on there?
Gordon: I am not intimately involved in the situation in California, but I have addressed some issues as the executive director of the National Academy of MUA Physicians.
First and foremost, it is my understanding that you are innocent until proven guilty, in this country, under the constitution; that is, unless you are a chiropractor—in which case, you are guilty by profession and then you must prove your innocence. That is exactly how I feel about this case in California. If, in fact, there are 4 chiropractors who have abused the insurance system by falsely filing insurance claims, then maybe they should be charged with something. If, in fact, they have actually filed these claims, and it is proven within a reasonable certainty that these chiropractors were guilty of this fraudulent practice, then I will be the first one to condemn their actions.
The problem here is that these chiropractors have been tried in the media already, and have not been given a chance to present their side of the story.
Compounding that is the ridiculous charge that these chiropractors are practicing medicine without a license because they were performing MUA in a surgery center. No board in the United States, that I know of, determines where manipulation by a chiropractic physician is to be performed, as long as the chiropractor has a license to practice in that state, has clinically justified the procedure which he/she is performing on the patient and has the patient’s permission to perform the procedure used on them.
TAC: Is there anything else that the reader should want to consider before becoming involved in the MUA technique.
Gordon: Yes. This is not just an additional technique to build your practice. If you are being taught the MUA procedure as an easy way to build your practice, then you need to consider who is teaching the course. If you perform this procedure properly and follow the standards and protocols as outlined by the National Academy of MUA Physicians, and now the textbook that is out there, then you will not only have a tremendous procedure to add to your treatment regime but, more importantly, a great new option for your chronic pain patients. The results that we have achieved over the past 20 years since the chiropractic physicians have been involved are nothing short of amazing and, in some cases, hard to believe. It is because we have taken an old, widely recognized procedure that was primarily performed in the osteopathic profession for many years and brought the skills of chiropractic to the arena that this procedure has achieved the results it has. I know this, because I have been studying and performing MUA since 1985. I’ve seen the changes; I know it works; and I’ve been privileged to see the miraculous results I speak of.
The problem today, as I see it, revolves around some of our colleagues using this procedure to enhance their financial bases and forgetting why we are doing this procedure in the first place. And, then, there are the insurance carriers that often view chiropractors as people that don’t belong in the operating room and don’t think that the skills we bring to this procedure should be used in such a manner as MUA.
Nonetheless, this procedure has it’s own CPT code and I have written a great many articles to support my position about the validity of that CPT code for MUA. The bottom line is, that CPT Code for MUA of the spine (22505) has been in that codebook for over 20 years.
Insurance Providers Benefit by Approving MUA
Manipulation Under Anesthesia is more accepted now than at anytime in the past, but it has had a long, difficult path to reimbursement. For years, MUA was denied because it was considered new or experimental. But, in the past few years, insurance carriers have had a much tougher time with that argument because of the preponderance of case studies and documentation that underline MUA’s effectiveness. In fact, the insurance companies lose almost all arbitrations brought on the grounds of non-valid treatment. So, the new battleground for MUA practitioners concerns fees.
Insurance companies are now trying to deny MUA claims because of “exorbitant fees,” and there have been abuses. However, in order to remedy the situation, there is a new organization being formed. The International Independent MUA Physicians Association (IIMUAPA) is being formed by Dr. Robert C. Gordon, along with a group of 200 other physicians, to unite MUA doctors and establish protocols and standards, including a “reasonable and customary” fee structure everybody can live with. Thus far, response from insurance carriers and regulatory agencies has been positive.
The insurance companies argue, though, that MUA is the same as regular conservative care in an office setting and should be compensated accordingly. MUA practitioners cite the multidisciplinary environment, hospital setting, use of anesthesia, and training and certification required to perform the procedure as justification for more. And, then, there is the liability issue.
“MUA is an advanced technique and practitioners should be paid fairly for their expertise,” says Gordon. “The bottom line is, insurance carriers have been so consumed with trying to deny MUA for various reasons that they haven’t realized the benefits that MUA is bringing to their own ‘claims made’ table.” Typical results have been a staggering 70-80% good to excellent in the top range of improvement with properly selected patients, and an additional 50-70% fair results with a majority of other patients who receive the MUA procedure. The accepted MUA failure rate is just 5% with properly selected patients. Failures continue to range either from no improvement to no worse, or involve patients who are pain dependent and would not have recovered no matter what type of care was rendered.
“So, when I look at the benefits the insurance industry is casually pushing aside, it makes me wonder what the real agenda is for this industry in the United States,” says Gordon.
The benefits to the insurance industry of approving MUA include:
• Patients return to the work site with increased productivity.
• Patients recover from months of lifestyle changing incapacities.
• Patients are able to return to the working environment, which has a distinct impact on the economy and economic output.
• Patients stop having to use their insurance coverage for neuromusculoskeletal problems that have been resolved.
• Chronic pain patients have another alternative treatment to suggest to their insurance carrier before surgery is required. This is vital to prevent the large volume of failed back surgeries frequently seen in the MUA arena.
• Patients respond to MUA and post care at a significantly higher rate than with other, more prolonged, conservative programs of PT, minimally invasive surgeries, injection therapy, and office-based, minimally responsive manual therapy programs with properly selected cases.
1- Capps, S., Texas College of Chiropractic, syllabus: Manipulation Under Anesthesia; postgraduate course of study, 1992.
2- Chrisman, OD, et al. A study of the results following rotary manipulation of the lumbar intervertebral disc syndrome. J Bone Joint Surg., 1964; 46-A:517
3- Krunhansl, BR, and Nowacek CJ, Manipulation Under Anesthesia. Modern Manual Therapy, 1988, pp. 777-786.
4- Kohlbeck, F. , Haldeman, S., technical assessment: medication assisted spinal manipualtion; Spine Journal, North American Spine Society, Vol. 2, July/ August, 2002.
5- Mensor, R., “non-operative treatment, including manipulation for lumbar intervertebral disc syndrome”, J Bone Joint Surg., Vol. 5, Oct. 1955. pp. 925-936.
6- Gordon, R; Manipulation Under Anesthesia, Concepts in Theory and Application; 2005, Chapter 2, Francis, R.; CRC Press, Taylor and Francis; Boca Raton, London, New York, Singapore. pp.13-23.
Dr. Robert C. Gordon is the author/editor of the textbook Manipulation Under Anesthesia, Concepts in Theory and Application, published in April 2005 by Taylor & Francis (CRC Press). He is a member of the postgraduate faculty of the National University of Health Sciences in Lombard, IL. Dr. Gordon teaches MUA throughout the United States and has recently been asked to start teaching MUA outside the United States. He was recently inducted into the Royal College of Physicians & Surgeons (US) and is the Vice Chairman of the Royal College of Chiropractic Medicine.