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Temporomandibular joint (TMJ) dysfunction may be the result of congenital and developmental anomalies; fractures and dislocations resulting from trauma, internal derangement, or ankylosis (stiffening or fixation of a joint); or arthritic and neoplastic diseases. 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, disk 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.

• Diagnostic x-ray, tomograms, and arthrograms
• CT scan or MRI (generally CT scans and MRI's are reserved for pre-surgical evaluations)
• Cephalograms (x-rays of jaws and skull)
• Pantograms (x-rays of maxilla and mandible)

The following surgical procedures are considered medically necessary in the treatment of TMJ dysfunction:

• Arthrocentesis
• Manipulation for reduction of fracture or dislocation of the TMJ
• Arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment.
• Open surgical procedures including, but not limited to, arthroplasties, condylectomies, meniscus or disc plication and disc removal when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed conservative treatment
• Splints inserted after surgery are appropriate. Splints used in place of surgery are medically necessary (5-16-2002).
• Intra-oral reversible prosthetic devices/appliances (encompassing fabrication, insertion and adjustment); There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits (added 5-16-2002).

The following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction:

• Electromyography (EMG), including surface EMG
• Kinesiography
• Thermography
• Neuromuscular junction testing
• Somatosensory testing
• Transcranial or lateral skull x-rays
• Ultrasound imaging/Sonogram
• Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJ dysfunction)
• Muscle testing
• Standard dental radiographic procedures
• Range of motion measurements
• Computerized mandibular scan (this measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJ dysfunction).
• Arthroscopy of the TMJ for purely diagnostic purposes

The following non-surgical treatments of TMJ are not medically necessary:

• Electrogalvanic stimulation - See Neuromuscular Electrical Stimulation (NMES)
• Iontophoresis -
• Biofeedback - See Biofeedback
• Ultrasound
• Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function

Passive rehabilitation therapies, including continuous passive motion (see CPM), manual stretching, and stretching using hand-held devices, are used for patients who are unable to open their mouths adequately due to temporomandibular joint (TMJ) disease, TMJ surgery, scars, or contractures resulting from burns or radiation therapy. The goal of passive rehabilitation therapy is to increase the mobility of the jaw, increase the range of motion of the TMJ, and increase the size of the mouth opening.

Other types of passive rehabilitation therapy are available, including the passive stretch provided by the Therabite Jaw Motion Rehabilitation System (Therabite, Inc., West Chester, PA), which is a handheld, patient-operated device consisting of padded bite plates attached to a scissors-like device. The mouth opening is stretched to the maximum comfortable position for several seconds at a time, and this is repeated 5 to 10 times, several times a day (Buchbinder et al., 1993; Maloney et al., 2002; Therabite, Inc., 2002).

• Orthodontic services
• Dental restorations/prostheses
• TENS (transcutaneous electrical nerve stimulation) - See TENS
• PENS (percutaneous electrical nerve stimulation) - See PENS
• Physical therapy, including diathermy, infrared, and heat and cold treatment, and manipulation
• Acupuncture
• Low-level laser therapy
• Hyaluronic acid

None

Investigative 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.

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.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. 

Non-Covered Codes

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