Temporomandibular Joint Disorder

POLICY NUMBER

A.2.01.21

DESCRIPTION

Temporomandibular joint disorder (TMJD) refers to a group of disorders characterized by pain in the temporomandibular joint 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.

Diagnosis of Temporomandibular Joint Disorder

In the clinical setting, TMJD is often a diagnosis of exclusion and involves physical examination, patient interview, and a review of dental records. Diagnostic testing and radiologic imaging are generally only recommended for patients with severe and chronic symptoms. Diagnostic criteria for TMJD have been developed and validated for use in both clinical and research settings.

Symptoms attributed to TMJD vary 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).

TreatmentFor many patients, symptoms of TMJD are short-term and self-limiting. Conservative treatments (eg, eating soft foods, rest, heat, ice, avoiding extreme jaw movements) and anti-inflammatory medication are recommended before considering more invasive and/or permanent therapies (eg, surgery).

Since 1981, several muscle-monitoring devices have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. Some examples are the K7x Evaluation System (Myotronics), the BioEMG III™ (Bio-Research Associates), M-Scan™ (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 TMJD.

Muscle-Monitoring Devices Cleared by the U.S. Food and Drug Administration

POLICY

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.

Diagnostic Procedures

The following diagnostic procedures are considered medically necessary in the diagnosis of temporomandibular joint disorder (TMJD):

• 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 diagnostic procedures are considered investigational in the diagnosis of TMJD:

• 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 gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJD;

• 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 TMJD);

• Arthroscopy of the TMJ for purely diagnostic purposes;

• Joint vibration analysis.

Surgical Treatments

The following surgical treatments are considered medically necessary in the treatment of TMJD:

• Arthrocentesis;

• Manipulation for reduction of fracture or dislocation of the TMJ;

• Arthroscopic surgery in individuals 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 TMJD is the result of congenital anomalies, trauma, or

  disease in individuals who have

  failed conservative treatment;

• Splints inserted after surgery are appropriate. Splints used in place of surgery are medically necessary.

Non-Surgical Treatments

The following non-surgical treatments are considered medically necessary in the treatment of TMJD:

• Intra-oral removable 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.)

• Physical therapy

The following non-surgical treatments are considered investigational in the treatment of TMJD:

• Electrogalvanic stimulation - See Neuromuscular Electrical Stimulation (NMES) ;

• Iontophoresis;

• Biofeedback ;

• Ultrasound;

• Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function;

• Orthodontic services;

• Dental restorations/prostheses;

• Transcutaneous Electrical Nerve Stimulation ;

• Percutaneous Electrical Nerve Stimulation

  ;

• Acupuncture;

• Low-level laser therapy;

• Hyaluronic acid;

• Platelet concentrates;

• Dextrose prolotherapy;

• Passive rehabilitation therapies, including  Continuous Passive Motion (CPM) in the Home Setting , manual stretching, stretching using hand-held devices, and other types of passive rehabilitation therapy, 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.

POLICY EXCEPTIONS

Federal Employee Program (FEP) members: Refer to the Member's Plan for benefits, limitations, and/or exclusions for these services.

State Health Plan (State and School Employees) Members: Benefits are not provided for physical therapy, orthodontics, dentures, occlusal reconstruction, or for crowns or inlays.

POLICY GUIDELINES

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 Mental Health Disorders, 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 medical necessity, “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 HISTORY

5/1992: "Arthroscopy of the Temporomandibular Joint" approved by Medical Policy Advisory Committee (MPAC).

11/1997: Comprehensive 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.

03/02/2017: Policy description updated regarding diagnostic criteria and devices. Investigational policy statement criteria for diagnostic procedures updated to change "gothic" to "gnathic."

12/20/2017: Code Reference section updated to add new 2018 HCPCS codes D5511, D5512, D5611, D5612, D5621, D5622, and D8695. Revised code descriptions for CPT code 64550 and HCPCS codes D1555, D4230, D4231, and J7321. Removed deleted ICD-10 diagnosis codes M26.60, M26.61, M26.62, M26.63, S03.0XXA, S03.4XXA and ICD-9 diagnosis codes 524.61, 524.62, 524.63, 524.64, 830.0, 830.1, and 848.1.

02/26/2018: Policy title, description, and statement updated to change "Temporomandibular Joint Dysfunction" to "Temporomandibular Joint Disorder."

12/20/2018: Policy statements for non-surgical treatments updated to remove physical therapy from the list of investigational treatments and add as medically necessary in the treatment of TMJD. Code Reference section updated to move the following CPT codes from not medically necessary/investigational to covered: 97012, 97014, 97024, 97026, 97032, 97033, 97035, 97039, 97110, 97112, 97140, 97530, and 97799, effective 01/01/2019. Added new 2019 HCPCS codes D9130, D9944, D9945, and D9946 as covered. Added new 2019 HCPCS codes D1516, D1517, D1526, D1527, D5282, D5283, and D5876 as not medically necessary/investigational.

01/15/2019: Policy Exceptions updated to add the following statement: State Health Plan (State and School Employees) Members: Benefits are not provided for physical therapy, orthodontics, dentures, occlusal reconstruction, or for crowns or inlays. Code Reference section updated to remove deleted CPT code 64565 and deleted HCPCS codes D5510, D5610, and D5620.

03/19/2019: Policy description updated regarding devices. Policy statements unchanged.

12/19/2019: Code Reference section updated to add new HCPCS codes D1551, D1552, D1553, D1556, D1557, D1558, D1575, D2753, D5284, D5286, D8696, D8697, D8698, D8699, D8703, and D8704. Revised code descriptions for HCPCS codes D1510 and D1520. Removed deleted ICD-10 procedure codes 0RGC0ZZ, 0RGC3ZZ, 0RGC4ZZ, 0RGD0ZZ, 0RGD3ZZ, and 0RGD4ZZ. Effective 01/01/2020.

03/06/2020: Policy description updated regarding devices. Policy statements unchanged. Removed deleted HCPCS codes D9940 and D5281 and CPT code 64550.

09/30/2020: Code Reference section updated to add new ICD-10 diagnosis codes M26.641, M26.642, M26.643, M26.649, M26.651, M26.652, M26.653, and M26.659, effective 10/01/2020.

12/22/2020: Code Reference section updated to remove deleted HCPCS codes D1515 and D1525.

03/30/2021: Code Reference section updated to remove deleted HCPCS codes D1550, D1555, D8691, D8692, and D8693.

12/13/2021: Code Reference section updated to revise code description for HCPCS code D2971, effective 01/01/2022.

05/01/2022: Policy description updated regarding devices. Investigational policy statement for non-surgical treatments updated to include platelet concentrates. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add ICD-10 procedure codes 0RCC0ZZ, 0RCC3ZZ, 0RCC4ZZ, 0RCD0ZZ, 0RCD3ZZ, and 0RCD4ZZ to the covered codes table. Added CPT code 0232T as investigational.

11/11/2022: Policy reviewed. Investigational statement for non-surgical treatments updated to include dextrose prolotherapy.

12/20/2022: Code Reference section updated to add new HCPCS codes D0372 and D0374. Description for HCPCS code D0210 revised, effective 01/01/2023.

03/31/2023: Policy description updated regarding devices. Policy statement updated with minor wording changes. Code Reference section updated to add HCPCS code A4560. Removed deleted CPT codes 76101, 76102 and deleted HCPCS codes D8050, D8060, and D8690.

03/11/2024: Policy reviewed. Policy statement updated to change "patients" to "individuals."

12/23/2024: Code Reference section updated to revise the code description for HCPCS codes D2940 and D5520 effective 01/01/2025.

04/09/2025: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 2.01.21

CODE REFERENCE

This 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.

Covered Codes

Not Medically Necessary / Investigational Codes

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