Manipulation Under Anesthesia

Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. 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 (eg,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. 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 three or more consecutive days for best results. Care after manipulation under anesthesia may include four to eight 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 postepidural 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 (eg, frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

Regulatory Status

Manipulative procedures are not subject to regulation by the U.S. Food and Drug Administration.

Related Policies

• None

A. Spinal manipulation under anesthesia (MUA) is considered investigational for the treatment of pain syndromes of musculoskeletal origin including, but are not limited to, acute and chronic neck and back pain.

[INFORMATIONAL NOTE: There is lack of evidence from available published literature that spinal manipulation under anesthesia has been established as a safe and effective treatment for pain syndromes of musculoskeletal origin.

B. Any associated MUJA (manipulation under joint anesthesia) and/or MUESI (manipulation under epidural steroid injection) is (are) also considered investigational.

A. Manipulation under anesthesia (MUA) is considered medically necessary for the following indications when supported by unequivocal documentation in the member's medical records:
1. severe adhesive capsulitis of the shoulder (frozen shoulder) that is unresponsive to at least 3 months of conservative therapy that includes physical therapy and intra-articular corticosteroids;
2. arthrofibrosis of the knee with significant limitation in range of motion following trauma or surgery (e.g., ligament surgery, total knee arthroplasty) that is unresponsive to physical therapy.

B. Other indications for MUA of the shoulder or knee, and MUA of other body joints (e.g., hip, pelvis, ankle, elbow, wrist, temporomandibular joint) for any indication are considered investigational. There is insufficient data published in the scientific medical literature to support their safety and efficacy.

FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: The policy was created in 2005 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through February 11. 2020.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function, including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, two domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Manipulation Under Anesthesia
Clinical Context and Therapy Purpose

The purpose of manipulation under anesthesia is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as conservative management, in patients with chronic spinal, sacroiliac, or pelvic pain.

The question addressed in this policy is: Does manipulation under anesthesia improve the net health outcome in individuals with chronic spinal, sacroiliac, or pelvic pain?

The following PICO was used to select literature to inform this policy.

Patients

The relevant population of interest is individuals with chronic spinal, sacroiliac, or pelvic pain.

Interventions

The therapy being considered is manipulation under anesthesia.

Manipulation under anesthesia consists of a series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually with general anesthesia or moderate sedation). 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.

Patients with chronic spinal, sacroiliac, or pelvic pain are actively managed by orthopedic surgeons and primary care providers in an outpatient clinical setting; manipulation under anesthesia also involves the presence of an anesthesiologist.

Comparators

Comparators of interest include conservative management.

Conservative management includes steroid regimens, blood pressure medication, muscle relaxers, and physical therapy, and is managed by physical therapists and primary care providers in an outpatient clinical setting.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, quality of life, and treatment-related morbidity.

The existing literature evaluating manipulation under anesthesia as a treatment for chronic spinal, sacroiliac, or pelvic pain has varying lengths of follow-up, ranging from 2 weeks to 6 months. While studies described below all reported at least 1 outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, 6 months of follow-up is considered necessary to demonstrate efficacy.

Table 1 summarizes the patient-reported outcome measures described in this policy.

Table 1. Patient Self-Administered Outcome Measure Tools

Name	Description	Scoring	MCID
Numeric Pain Scale1,	Numbered scale by which patients rate their pain, similar to VAS	0-10 scale: 10=excruciating pain 0=no pain	Reduction of ≥2 points (≈30%) to be clinically important
Roland-Morris Disability Questionnaire2,	24 questions that measure low back pain-related disability	“Yes” answers are totaled to determine disability (1-24)Score of ≥14 represents significant disability	Change of ≥4 points required for clinically applicable change to be measured accurately
Bournemouth Questionnaire3,	7-question, multidimensional tool to assess outcome of care in a routine clinical setting Takes into account cognitive and affective aspects of pain Two versions: low back pain and nonspecific neck pain	Each question rated on a numeric rating scale from 0 to 10: 0=much better 5=no change 10=much worse Scores are totaled, for minimum of 0 and maximum of 70	Percentage improvement of 47% in back pain and 34% neck pain
Patient’s Global Impression of Change3,	7-point scale of how a patient perceives the efficacy of treatment, a rating of overall improvement from baseline	Scale of 1 to 7: 1=no change or condition is worse 2=almost the same 3=a little better, but no noticeable change 4=somewhat better, but no real difference 5=moderately better, slight noticeable change 6=better, definite improvement with real difference 7=a great deal better, considerable improvement	Clinically relevant improvement, response of ±6

MCID: minimal clinically important difference; VAS: visual analog scale.
Study Selection Criteria

Methodologically credible studies were selected using the following principles:

1. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
2. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
3. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

Dagenais et al (2008) conducted a comprehensive review of the history of manipulation under anesthesia or medicine-assisted manipulation and the published experimental literature.^4, They noted there was no research to confirm theories about a mechanism of action for these procedures and that the only RCT identified was published in 1971 when the techniques for spinal manipulation differed from those used presently.

Review of Evidence
Nonrandomized Comparative Studies

No high-quality RCTs have been identified. A comprehensive review of the literature by Digiorgi (2013)^5, described studies by Kohlbeck et al (2005)^6, and Palmieri and Smoyak (2002)^2, as being the best evidence available for medicine-assisted manipulation and manipulation under anesthesia of the spine.

Kohlbeck et al (2005) reported on a nonrandomized comparative study that included 68 patients with chronic low back pain. All patients received an initial 4- to 6-week trial of spinal manipulation therapy, after which 42 patients received supplemental intervention with manipulation under anesthesia and 26 continued with spinal manipulative therapy. Low back pain and disability measures favored the manipulation under anesthesia group over the spinal manipulative therapy only group at 3 months (adjusted mean difference on a 100-point scale, 4.4 points; 95% confidence interval [CI], -2.2 to 11.0). This difference attenuated at 1 year (adjusted mean difference, 0.3 points; 95% CI, -8.6 to 9.2). The relative odds of experiencing a 10-point improvement in pain and disability favored the manipulation under anesthesia group at 3 months (odds ratio, 4.1; 95% CI, 1.3 to 13.6) and 1 year (odds ratio, 1.9; 95% CI, 0.6 to 6.5).

Palmieri and Smoyak (2002) evaluated the efficacy of self-reported questionnaires to study manipulation under anesthesia in a convenience sample of 87 subjects from 2 ambulatory surgery centers and 2 chiropractic clinics. Thirty-eight patients with low back pain received manipulation under anesthesia and 49 received traditional chiropractic treatment. A numeric rating scale for pain and the Roland-Morris Disability Questionnaire were administered at baseline, after the procedure, and 4 weeks later. Average pain scale scores in the manipulation under anesthesia group decreased by 50% and by 26% in the traditional treatment group; Roland-Morris Disability Questionnaire scores decreased by 51% and 38%, respectively. Although the authors concluded that the study supported the need for large-scale studies on manipulation under anesthesia and that the assessments were easily administered and dependable, no large-scale studies comparing manipulation under anesthesia with traditional chiropractic treatment have been identified.

Observational Studies

Peterson et al (2014) reported on a prospective study of 30 patients with chronic pain (17 lower back, 13 neck) who underwent a single manipulation under anesthesia session with follow-up at 2 and 4 weeks.^7, The primary outcome measure was the Patient’s Global Impression of Change. At 2 weeks, 52% of the patients reported clinically relevant improvement (better or much better), with 45.5% improved at 4 weeks. There was a statistically significant reduction in numeric rating scale scores for pain at 4 weeks (p=0.01), from a mean baseline score of 4.0 to 3.5 at 2 weeks post-manipulation under anesthesia. Bournemouth Questionnaire scores improved from 24.17 to 20.38 at 2 weeks (p=0.008) and 19.45 at 4 weeks (p=0.001). This study lacked a sham group to control for a potential placebo effect. Also, the clinical significance of improved numeric rating scale and Bournemouth Questionnaire scores is unclear, although Hurst and Bolton (2004) described the Bournemouth Questionnaire as a percentage improvement of 47% in back pain and 34% in neck pain.^3,

West et al (1999) reported on a series of 177 patients with pain arising from the cranial, cervical, thoracic, and lumbar spine, as well as the sacroiliac and pelvic regions who had failed conservative and surgical treatment.^8, Patients underwent three sequential manipulations with intravenous sedation followed by 4 to 6 weeks of spinal manipulation and therapeutic modalities; all had 6 months of follow-up. On average, visual analog scale scores improved by 62% in patients with cervical pain and by 60% in patients with lumbar pain. Dougherty et al (2004) retrospectively reviewed outcomes of 20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation after epidural injection.^9, After epidural injection of lidocaine (guided fluoroscopically or with computed tomography), methylprednisolone acetate flexion distraction mobilization and then high-velocity, low-amplitude spinal manipulation were delivered to the affected spinal regions. Outcome criteria were empirically defined as a significant improvement, temporary improvement, or no change. Among lumbar spine patients, 22 (37%) noted significant improvement, 25 (42%) reported temporary improvement, and 13 (22%) no change. Among patients receiving a cervical epidural injection, 10 (50%) had significant improvement, 6 (30%) had temporary relief, and 4 (20%) had no change.

The only study on manipulation under joint anesthesia or analgesia found evaluated 4 subjects; it was reported by Dreyfuss et al (1995).^10, Later, Michaelsen (2000) noted that joint-related manipulation under anesthesia should be viewed with “guarded optimism because its success is based solely on anecdotal experience.”^11,

Table 2. Summary of Characteristics of Key Observational Comparative Studies of Manipulation Under Anesthesia

Study	Study Type	Country	Dates	Participants	Treatment	Follow-Up
Peterson (2014)7,	Prospective	Switzerland	NR	Patients (N=30) with chronic pain who underwent single MUA session	MUA for those with low back pain (N=17); MUA for those with neck pain (n=13)	2 and 4 weeks
West (1999)8,	Case series	US	July 1995-Feb 1997	177 patients with pain arising from the cranial, cervical, thoracic, and lumbar spine, as well as the sacroiliac and pelvic regions who had failed conservative and surgical treatment	Patients underwent 3 sequential manipulations with intravenous sedation followed by 4 to 6 weeks of spinal manipulation and therapeutic modalities	6 months
Dougherty (2004)9,	Retrospective	US	Nov 1996-Nov 2000	20 cervical and 60 lumbar radiculopathy patients who underwent spinal manipulation after epidural injection. The patients ranged in age from 21-76 years with an average age of 43 years.Forty-three percent of the patients were female and 57% were male.	Following epidural injection of lidocaine (guided fluoroscopically or with computed tomography), methylprednisolone acetate flexion distraction mobilization and high-velocity, low-amplitude spinal manipulation were delivered to the affected spinal regions	1-year

MUA: manipulation under anesthesia; NR: not reported.
Table 3. Summary of Results of Key Observational Comparative Studies of Manipulation Under Anesthesia

Study	Improvement as Reported by Participant	Bournemouth Questionnaire Scores	Patient’s Global Impression of Change
Peterson (2014)7,
Baseline		24.17
2-weeks post		20.38 (p=0.008)
4-weeks post		19.45 (p=0.001)
“better or much better” reported at 2 weeks post			52%
“better or much better” reported at 4 weeks post			45.5%
West (1999)8,
% of cervical pts with improvement			62%
% of lumbar pts with improvement			60%
Dougherty (2004)9,
Lumbar spine pts.
% noting significant improvement	22 (37%)
% noting temporary improvement	25 (42%)
% noting no improvement	13 (22%)
Pts. receiving cervical epidural injection
% noting significant improvement	10 (50%)
% noting temporary improvement	6 (30%)
% noting no improvement	4 (20%)

Pts: Patients.
Summary of Evidence

For individuals who have chronic spinal, sacroiliac, or pelvic pain who receive manipulation under anesthesia, the evidence includes case series and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Scientific evidence on spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is very limited. No randomized controlled trials have been identified. Evidence on the efficacy of manipulation under anesthesia over several sessions or for multiple joints is also lacking. The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION
Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 2 physician specialty societies and 4 academic medical centers while this policy was under review in 2009. Input from the 7 reviewers agreed that manipulation under anesthesia for chronic spinal and pelvic pain is investigational.

Practice Guidelines and Position Statements
American Association of Manipulation Under Anesthesia Providers

In 2014, The American Association of Manipulation Under Anesthesia Providers published consensus-based guidelines for the practice and performance of manipulation under anesthesia.^12, The guidelines included patient selection criteria (see below), establishing medical necessity, frequency and follow-up procedures, parameters for determining manipulation under anesthesia progress, general post-manipulation under anesthesia therapy, and safety. The guidelines recommended 3 consecutive days of treatment, based on the premise that serial procedures allow a gentler yet effective treatment plan with better control of biomechanical force. The guidelines also recommended follow-up therapy without anesthesia over 8 weeks after manipulation under anesthesia that includes all fibrosis release and manipulative procedures performed during the manipulation under anesthesia procedure to help prevent re-adhesion.

Patient selection criteria include, but are not limited to, the following:

• "The patient has undergone an adequate trial of appropriate care...and continues to experience intractable pain, interference to activities of daily living, and/or biomechanical dysfunction.
• "Sufficient care has been rendered prior to recommending manipulation under anesthesia. A sufficient time period is usually considered a minimum of 4-8 weeks, but exceptions may apply depending on the patient's individual needs....
• "Physical medicine procedures have been utilized in a clinical setting during the 6-8 week period prior to recommending manipulation under anesthesia.
• "Diagnosed conditions must fall within the recognized categories of conditions responsive to manipulation under anesthesia. The following disorders are classified as acceptable conditions for utilization of manipulation under anesthesia:
  1. "Patients for whom manipulation of the spine or other articulations is the treatment of choice; however, the patient's pain threshold inhibits the effectiveness of conservative manipulation.
  2. "Patients for whom manipulation of the spine or other articulations is the treatment of choice; however, due to the extent of the injury mechanism, conservative manipulation has been minimally effective...and a greater degree of movement of the affected joint(s) is needed to obtain patient progress.
  3. "Patients for whom manipulation of the spine or other articulations is the treatment of choice by the doctor; however due to the chronicity of the problem, and/or the fibrous tissue adhesions present, in-office manipulation has been incomplete and the plateau in the patient's improvement is unsatisfactory.
  4. "When the patient is considered for surgical intervention, MUS is an alternative and/or an interim treatment and may be used as a therapeutic and/or diagnostic tool in the overall consideration of the patient's condition.
  5. "When there are no better treatment options available for the patient in the opinions of the treating doctor and patient."^12,

Not applicable.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in February 2020 did not identify any ongoing or unpublished trials that would likely influence this review.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Manipulation Under Anesthesia
Elbow Manipulation Under Anesthesia
Hip Manipulation Under Anesthesia
Knee Manipulation Under Anesthesia
Manipulation of Spine Under Anesthesia
Manipulation of Other Body Joints Under Anesthesia
Manipulation Under Anesthesia (MUA)
MUA (Manipulation Under Anesthesia)
Shoulder Manipulation Under Anesthesia
Spinal Manipulation Under Anesthesia
MUJA
MUESI

References:
1. Farrar JT, Young JP, LaMoreaux L et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov;94(2). PMID 11690728

2. Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther. Oct 2002;25(8):E8-E17. PMID 12381983

3. Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther. 2004 Jan;27(1). PMID 14739871

4. Dagenais S, Mayer J, Wooley JR, et al. Evidence-informed management of chronic low back pain with medicine- assisted manipulation. Spine J. Jan-Feb 2008;8(1):142-149. PMID 18164462

5. Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. May 14 2013;21(1):14. PMID 23672974

6. Kohlbeck FJ, Haldeman S, Hurwitz EL, et al. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther. May 2005;28(4):245-252. PMID 15883577

7. Peterson CK, Humphreys BK, Vollenweider R, et al. Outcomes for chronic neck and low back pain patients after manipulation under anesthesia: a prospective cohort study. J Manipulative Physiol Ther. Jul-Aug 2014;37(6):377- 382. PMID 24998720

8. West DT, Mathews RS, Miller MR, et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther. Jun 1999;22(5):299-308. PMID 10395432

9. Dougherty P, Bajwa S, Burke J, et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther. Sep 2004;27(7):449-456. PMID 15389176

10. Dreyfuss P, Michaelsen M, Horne M. MUJA: manipulation under joint anesthesia/analgesia: a treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther. Oct 1995;18(8):537- 546. PMID 8583177

11. Michaelsen MR. Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin. J Manipulative Physiol Ther. Feb 2000;23(2):127-129. PMID 10714542

12. Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. Feb 03 2014;22(1):7. PMID 24490957

(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

00640
22505
21073
23700
24300
25259
26340
27275
27570
27860