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DESCRIPTIONTemporomandibular joint (TMJ) dysfunction refers to a group of disorders characterized by pain in the TMJ and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of non-surgical and surgical treatment possibilities for patients whose symptoms persist.
Temporomandibular joint dysfunction (also known as TMJ disorders) refers to a cluster of problems associated with the TMJ and musculoskeletal structures. The etiology of TMJ disorders remains unclear and is believed to be multifactorial. TMJ disorders are often divided into two main categories: articular disorders (e.g., ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, and joint dislocation) and masticatory muscle disorders (e.g., myofascial pain, myofibrotic contracture, myospasm, and neoplasia).
There are no generally accepted criteria for diagnosing TMJ disorders. It is often a diagnosis of exclusion and involves physical examination, patient interview, and dental record review. Diagnostic testing and radiologic imaging is generally only recommended for patients with severe and chronic symptoms.
Symptoms attributed to TMJ dysfunction are varied and include, but are not limited to: clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).
For many patients, symptoms of TMJ dysfunction are short-term and self-limiting. Conservative treatments such as eating soft foods, rest, heat, ice, and avoiding extreme jaw movements, and anti-inflammatory medication, are recommended prior to consideration of more invasive and/or permanent therapies such as surgery.
Several muscle monitoring devices have received clearance from the U.S. Food and Drug Administration (FDA) through the 510(k) process since 1981. Some examples of these devices are: the K6-I Diagnostic System (Myotronics), the BioEMG III™ (Bio-Research Associates), and the GrindCare Measure (Medotech A/S). These devices aid clinicians in the analysis of joint sound, vibrations, and muscle contractions when diagnosing and evaluating TMJ dysfunction.
POLICYEffective 01/01/2014, prior authorization is required for temporomandibular joint disorder benefits.
Medical Necessity documentation and a treatment plan, including charges for each service, must be submitted to and approved prior to the commencement of treatment. No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider.
The following diagnostic procedures are considered medically necessary in the diagnosis of TMJ dysfunction:
The following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction:
The following surgical treatments are considered medically necessary in the treatment of TMJ dysfunction:
The following non-surgical treatments are considered medically necessary in the treatment of TMJ dysfunction:
The following non-surgical treatments are considered investigational in the treatment of TMJ dysfunction:
POLICY EXCEPTIONSState Health Plan (State and School Employees) and Federal Employee Program (FEP) members: Refer to the Member's Plan for benefits, limitations, and/or exclusions for these services.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Note that most member's benefits have a dollar lifetime limit on TMJ services which include all services related to TMJ including diagnosis and treatment.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY5/1992: "Arthroscopy of the Temporomandibular Joint" approved by Medical Policy Advisory Committee (MPAC)
11/1997: Comprensive update approved by Medical Policy Advisory Committee; policy renamed
10/23/2000: Splints inserted after surgery are appropriate. Splints used in place of surgery are not medically necessary.
6/15/2001:Code Reference section updated; ICD-9 Procedure codes 80.21 and 80.51 deleted, ICD-9 Diagnosis codes 715.90 and 722.1-.2 deleted, Non-Covered codes added, Managed Care Requirements deleted, Prior Authorization deleted
2/13/2002: Investigational definition added
3/19/2002: "Cephalogram and Pantogram" review on an individual basis requirement has been deleted
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated
5/2002: Reviewed by MPAC, intra-oral reversible prosthetic devices/appliances moved to medically necessary. There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated
12/16/2002: HCPCS S8262 added
3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately
6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 deleted from non-covered, HCPCS D2940 deleted from non-covered
3/23/2006: Coding updated. CPT4 2005 & 2006 revisions added to policy.
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/28/2008: Code reference section updated: ICD-9 diagnosis 524.64 added to covered. CPT codes 21070, 21085, 21110, 76101, 76102, 97762 added to covered. ICD-9 procedure code 80.29 added to covered. CPT codes 64555-64595, 90875, 90876, 97012, 97110, 97112, 97530, 97799 added to non-covered. CPT codes 21025-21049, 21141-21147, 21150, 21151, 21193-21196, 21198, 21199, 21244-21255, 21440-21470, 70100, 70110, 70140, 70150, 70250, 70260 removed from covered table. ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table.
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment.
10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table.
03/07/2011: Added new CPT codes 64568, 64569, and 64570 to the Code Reference section.
09/23/2011: Clarified policy statement regarding ultrasound. Deleted outdated references from the Sources section.
09/25/2012: Added low-level laser therapy and hyaluronic acid to the list of investigational nonsurgical treatments. Added 97039 and J7321-J7326 to the Non-Covered Codes table.
11/15/2013: Policy statement re-formatted for clarity purposes. Intra-oral "reversible" prosthetic devices changed to intra-oral "removable" prosthetic devices for clarification only. Joint vibration analysis added as an investigational diagnostic procedure.
02/17/2014: Added the following verbiage to the Policy section: Effective 01/01/2014, prior authorization is required for temporomandibular joint disorder benefits. Medical Necessity documentation and a treatment plan, including charges for each service, must be submitted to and approved prior to the commencement of treatment. No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider. Added CPT codes D0368, D0384, and S8262 to the Covered Codes table. Removed deleted CPT code D0360 from the Code Reference section.
09/19/2014: Policy reviewed; description updated. Policy statement unchanged.
12/31/2014: Code Reference section updated to revise the description of the following CPT code: 20605. Effective 1/1/15. Added the following new 2015 CPT code(s) to the Code Reference section: 20606.
09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35.
09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table.
12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875.
02/19/2016: Policy description updated regarding devices. Policy statement unchanged.
06/01/2016: Policy number A.2.01.21 added.
09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: M26.601 - M26.609, M26.611 - M26.619, M26.621 - M26.629, M26.631 - M26.639, S03.00XA, S03.01XA, S03.02XA, S03.03XA, S03.40XA, S03.41XA, S03.42XA, and S03.43XA.
12/30/2016: Code Reference section updated to add new 2017 HCPCS code D1575. Removed deleted HCPCS codes S8262 and D2970.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
64550, 64553, 64555, 64560, 64561, 64565, 64568, 64569, 64570, 64573, 64575, 64577, 64580, 64581, 64585, 64590, 64595
Unlisted ultrasound procedure
Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy code range
Biofeedback training by any modality
Needle electromyography; cranial nerve supplied muscle(s), unilateral
Needle electromyography; cranial nerve supplied muscles, bilateral
Short-Latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method
Unlisted neurological or neuromuscular diagnostic procedure
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics;
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; with dynamic plantar pressure measurements during walking
Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
Physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
Application of a modality to one or more areas; hot or cold packs
Applicaton of a modality to one or more areas; traction, mechanical
Application of a modality to one or more areas; electrical stimulation (unattended)
Application of a modality to one or more areas; diathermy (eg, microwave)
Application of a modality to one or more areas; infrared
Application of a modality to one or more areas, electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; iontophoresis, each 15 minutes
Application of a modality to one or more areas; ultrasound, each 15 minutes
Unlisted modality (specify type and time if constant attendance)
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
Unlisted physical medicine/rehabilitation service or procedure
Electrical stimulator supplies, 2 lead, per month (e.g. TENS, NMES)
Replacement batteries. Medically necessary transcutaneous electrical stimulator, owned by patient
D0210, D0220, D0230
Intraoral x-rays code range
D1510, D1515, D1520, D1525, D1550
Space maintainers code range
Removal of fixed space maintainer
|D1575||Distal show space maintainer – fixed – unilateral (New 01/01/2017)|
D2140, D2150, D2160, D2161, D2330, D2331, D2332
Amalgam restorations code range
D2335, D2390, D2391, D2392, D2393, D2394
Resin-based composite restorations code range
D2410, D2420, D2430
Gold foil restorations code range
D2510, D2520, D2530
Inlay - metallic restorations code range
D2542, D2543, D2544
Onlay – metallic restorations code range
D2610, D2620, D2630
Inlay - porcelain/ceramic restorations code range
D2642, D2643, D2644
Onlay - porcelain/ceramic restorations code range
D2650, D2651, D2652
Inlay - resin-based composite composite/resin restorations code range
D2662, D2663, D2664
Onlay - resin-based composite composite/resin restorations code range
D2710, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2799
Crowns code range
Recement cast or prefabricated post and core
D2930, D2931, D2932, D2933, D2934
Prefabricated stainless steel crowns code range
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Post and core in addition to crown, indirectly fabricated
Each additional indirectly fabricated post - same tooth
Prefabricated post and core in addition to crown
Post removal (not in conjunction with endodontic therapy)
Each additional prefabricated post - same tooth
D2960, D2961, D2962
Labial veneer restorations code range
Temporary crown (fractured tooth)
Crown repair, by report
Unspecified restorative procedure, by report
Anatomical crown exposure - four or more contiguous teeth per quadrant
Anatomical crown exposure - one to three teeth per quadrant
D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5225, D5226, D5281
Complete and partial dentures code range
D5410, D5411, D5421, D5422
Adjustments to removal prostheses code range
Repair broken complete denture base
Replace missing or broken teeth - complete denture (each tooth)
D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671
Repair to partial dentures
D5710, D5711, D5720, D5721
Denture rebase procedures code range
D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
Denture reline procedures
D5810, D5811, D5820, D5821
Interim prothesis code range
D5850, D5851, D5860, D5861, D5862, D5867, D5875, D5899
Other removable prosthetic services
Recement implant/abutment supported crown
Recement implant/abutment supported fixed partial denture
Arthroscopy, diagnostic with or without biopsy
D8010, D8020, D8030, D8040, D8050, D8060, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8690, D8691, D8692, D8693, D8999
Other orthodontic treatment code range
Heat lamp, without stand (table model), includes bulb, or infrared element
Heat lamp, with stand, includes bulb, or infrared element
Infrared heating pad system
TENS device, two lead, localized stimulation
TENS device; four or more leads, for multiple nerve stimulation
Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
Electromyography (emg), biofeedback device
Continuous passive motion exercise device, not otherwise specified
Hyaluronan or derivative code range
Surface electromyography (emg)
Other diagnostic procedures on facial bones and joints (Arthroscopy)
Inspection of Right Temporomandibular Joint, Open Approach
Inspection of Right Temporomandibular Joint, Percutaneous Approach
Inspection of Right Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Right Temporomandibular Joint, External Approach
Inspection of Left Temporomandibular Joint, Open Approach
Inspection of Left Temporomandibular Joint, Percutaneous Approach
Inspection of Left Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Left Temporomandibular Joint, External Approach
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