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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., myofacial 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.
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.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
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.
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.
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.
Not Medically Necessary / Investigational Codes