Temporomandibular Joint Dysfunction (TMJD)

Description of Procedure or Service

Temporomandibular joint (TMJ) dysfunction (also known as TMJ disorders or TMJD) refers to a cluster of problems association 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, disk derangement disorders, fractures, inflammatory disorders, osteoarthritis and joint dislocation) and masticatory muscle disorders (e.g., myofacial pain, myofibrotic contracture, myospasm and neoplasia).

In the clinical setting, TMJ dysfunction is often a diagnosis of exclusion, and involves physical examination, individual interview, and review of dental records. Diagnostic testing and radiologic imaging is generally only recommended for individuals with severe and chronic symptoms. Diagnostic criteria for temporomandibular disorders have been developed and validated for use in both clinical and research settings. Symptoms attributed to TMJD 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).

Most TMJ symptoms resolve over time, but a significant percentage requires a year or more to do so. The seriousness of the symptoms also varies greatly. On the other hand, the pathology tends to be progressive and can result in loss of condylar bone and development of facial deformity. Non-surgical treatment should be considered for all symptomatic individuals with internal derangement and osteoarthritis. 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.

Regulatory Status

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 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. dysfunction.

Related Policies:

Prolotherapy

TENS (Transcutaneous Electrical Nerve Stimulator)

Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for the evaluation and treatment of temporomandibular joint (TMJ) dysfunction when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Also see Policy Guidelines.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design, and may include or exclude services commonly recommended for the evaluation and treatment of Temporomandibular Joint Dysfunction, such as, but not limited to, bite splints or oral orthotic appliances, physical therapy, and/or TMJ surgery. Nightguard appliances for treatment of nocturnal bruxism, braces and orthodontic treatment of TMJD are considered dental therapy and are not eligible under medical benefits. Therefore, member benefit language should be reviewed before applying the terms of this medical policy.

Treatment of TMJ included in this policy may require prior review (prior plan approval).

When Evaluation and Treatment of Temporomandibular Joint Dysfunction (TMJD) is covered

1. Diagnostic procedures.
   MRI may be considered medically necessary when both of the following criteria are met:
   1. Conservative measures noted below have not resolved signs and/or symptoms; and
   2. The results of the MRI will impact decisions regarding surgical intervention.
      Note: MRI may require prior review by BCBSNC’s diagnostic imaging management program.
2. Non-surgical treatments.
   Short term physical therapy when administered by a licensed physical therapist (see Corporate Medical Policy titled “Rehabilitative Therapies”), intra-oral removable orthotic devices/appliances (encompassing fabrication, insertion and adjustment), and arthrocentesis may be considered medically necessary when both of the following criteria are met:
   1. Significant clinical symptoms and signs are present, including at least two of the following:
      1. Extra-articular pain related to muscles of the head and neck region, or earaches, headaches, masticatory or cervical myalgias;
      2. Painful chewing;
      3. Restricted range of motion, manifested by one of the following:
         1. interincisal opening of less than 35 mm. (greatest distance between front upper teeth and lower front teeth when mouth is wide open); or
         2. lateral excursive movement of less than 4 mm. (side to side movement); or
         3. protrusive excursive movement of less than 4 mm. (front to back motion); or
         4. deviation on opening of greater than 5 mm. and
   2. Symptoms are not resolved by conservative treatment, including all of the following:
      1. Removal of precipitating activities (gum chewing, eating hard candies); and
      2. Pharmacological treatment (such as anti-inflammatory, analgesic, or muscle relaxant medications (2 week trial); and
      3. 2 week trial of soft diet and proper chewing techniques;
3. Surgical treatments.
   1. TMJ Surgery May be considered medically necessary when all of the following criteria are met:
      1. Signs and symptoms not resolved by conservative measures including standard splints (unless contra- indicated, e.g., anterior open bite and some Class III malocclusions), pharmacological treatment and physical therapy (unless contra- indicated); and
      2. MRI or other radiology studies document TMJ abnormality noted in Stage III-V below; and
      3. Underlying orthodontic disorders have been ruled out, or if present, treatment has been implemented (history, physical, and/or laboratory results must be documented with an assessment of the presence or absence of an orthodontic disorder).
   2. The following surgical procedures may be considered medically necessary in the treatment of TMJD:
      1. Arthrocentesis
      2. 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.
      3. Open surgical procedures including, but not limited to, arthroplasties; condylectomies; meniscus or disc placation and disc removal when TMJD is the result of congenital anomalies, trauma, or disease in individuals who have failed conservative treatment.
      4. Arthrotomy with total prosthetic joint replacement using the TMJ Concepts Patient Fitted TMJ Reconstruction Prosthesis ™ is indicated for reconstruction of the TMJ for treatment of end-stage TMJ disease, when no other viable therapeutic alternatives are available.
         1. Individuals should be considered for total prosthetic joint replacement if they have one or more of the following conditions:
            • Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment;
            • Recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment;
            • Failed tissue graft;
            • Failed alloplastic joint reconstruction;
            • Loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion.
         2. Total prosthetic joint replacement should not be used for individuals with one or more of the following conditions:
            • Active or suspected infections in or about the implantation site;
            • Uncontrollable masticatory muscle hyperfunction (clenching or grinding) which may lead to overload and loosening of screws;
            • Known allergy to any of the component materials.
      5. Orthognathic Surgery – addressed in separate policy titled “Orthognathic Surgery.”
      6. Therapeutic manipulation of the TMJ requiring anesthesia (i.e., general or monitored anesthesia care) for reduction of fracture or dislocation of the TMJ.

When Evaluation and Treatment of Temporomandibular Joint Dysfunction (TMJD) is not covered

1. Evaluation and treatment of temporomandibular joint dysfunction is considered not medically necessary when criteria are not met for the diagnostic tests and procedures addressed above.
2. 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; Intra-oral tracing or gnathic 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;
   • Ultrasound imaging/sonogram;
   • Joint vibration analysis
3. The following non-surgical treatments are considered investigational in the treatment of TMJ dysfunction:
   • Electrogalvanic stimulation;
   • Iontophoresis;
   • Biofeedback;
   • Ultrasound;
   • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function;
   • Orthodontic services;
   • Dental restorations
   • Dental prostheses (i.e., nightguard, occlusal guard, bruxism appliance);
   • Transcutaneous electrical nerve stimulation (TENS);
   • Percutaneous electrical nerve stimulation (PENS);
   • Acupuncture
   • Hyaluronic acid
   • Alpha-stim
   • Trigger point and tender point injections
   • Botulinum Toxin Injections
4. The following surgical treatments are considered investigational in the treatment of TMJ dysfunction:
   • Total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™
   • Partial joint replacement with the TMJ Fossa-Eminence Prosthesis™
5. Surgical treatment for Stage I and II TMJD symptoms (see table above) is considered not medically necessary.

Policy Guidelines

For individuals with suspected temporomandibular joint disorder (TMJD) who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test validity and other performance measures. None of the systematic reviews found that these diagnostic techniques accurately identified individuals with TMJD, and many of the studies had methodologic limitations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes randomized controlled trials (RCTs) and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Several studies, meta-analyses, and systematic reviews exploring the effectiveness of stabilization splints on TMJD pain revealed conflicting results. Overall, the evidence shows that stabilizing splints may improve pain and positively impact depressive and anxiety symptoms. The evidence related to pharmacologic treatment varies because studies, systematic reviews, and meta-analyses lack consistency in evaluating specific agents. Some systematic reviews have found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs. placebo]), but other studies showed a lack of benefit with agents such as methylprednisolone and botulinum toxin type A. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electric nerve stimulation , orthodontic services, hyaluronic acid , platelet concentrates, or dextrose prolotherapy, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic reviews did not find that these technologies reduced pain or improved functional outcomes significantly more than control treatments. Moreover, many individual studies were small and/or had methodologic limitations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with a confirmed diagnosis of TMJD who receive arthrocentesis or arthroscopy, the evidence includes RCTs, systematic reviews of RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One review, which included 3 RCTs, compared arthrocentesis or arthroscopy with nonsurgical interventions for TMJD. Pooled analyses of the RCTs found that arthrocentesis and arthroscopy resulted in superior pain reduction compared with control interventions. A network meta-analysis, which included 36 RCTs, revealed that arthroscopy and arthrocentesis improve pain control and maximum mouth opening. A third meta-analysis (N=8 RCTs) demonstrated superior pain reduction, but no difference in maximum mouth opening, with arthrocentesis compared to conservative therapies. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable Codes: 20605, 20606, 20611, 21010, 21050, 21060, 21070, 21073, 21240, 21242, 21243, 29800, 29804, 21116, D7880, D7881, S3900

Codes 21089 and 21299 should not be reported for orthotic to treat temporomandibular joint dysfunction. This is not an appropriate code because an orthotic or splint for treatment of temporomandibular joint disease is not an “unlisted maxillofacial prosthetic procedure.”

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

In addition to medical records, a letter of medical necessity is required for all requests for TMJ surgery and should include a detailed history of the condition, diagnostic imaging results and documentation of prior medical and surgical treatment.

Scientific Background and Reference Sources

From policy entitled: Temporomandibular Joint Dysfunction (TMJD) Treatment

Guidelines for Diagnosis and Management of Disorders involving the Temporomandibular joint and related musculoskeletal structures, Am Soc TMJ surgeons and Am Soc of Maxillofac Surg, 1992

AAOMS Parameters of Care, Temporomandibular Joint Surgery, AM Assoc Of Oral and Maxillofacial Surgeons, 1995

Tucker MR, Thomas EM. Temporomandibular disorders and dentofacial skeletal deformities. Selected Readings in Oral and Maxillofac Surg. 4:1-46, 1995.

Oral Surgery Consultant Panel – 10/99

Medical Policy Advisory Group – 12/99

Specialty Matched Consultant Advisory Panel – 5/2001

BCBSA Medical Policy Reference Manual – Review date 4/15/02 – Policy 2.01.21

BCBSA Medical Policy Reference Manual – Review date 4/29/03 – Policy 2.01.21

Specialty Matched Consultant Advisory Panel – 5/2003

Specialty Matched Consultant Advisory Panel – 5/2005

American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Dec 2000. Retrieved on April 28, 2006 from http://www.astmjs.org/guidelines.html

National Institutes of Health (NIH). Technology Assessment Conference Statement – Management of Temporomandibular Disorders. Bethesda, MD: NIH; April 29-May 1, 1996. Retrieved on April 10, 2006 from http://consensus.nih.gov/1996/1996TemporomandibularDisorders018html.htm

National Institutes of Health (NIH), National Institute of Dental and Craniofacial Research. TMD. Temporomandibular Disorders. NIH Publication No. 94-3487. Bethesda, MD: NIH; 2000. Retrieved on May 16,2006 from http://www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/TMDTMJ/TMD.htm

U.S. Food and Drug Administration. Dental products panel meeting summaries. May 10-11, 1999. Retrieved on April 28. 2006 from http://www.fda.gov/cdrh/panel/summary/dpp051099.html

U.S. Food and Drug Administration. TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis System. P980052 summary of safety and effectiveness. Retrieved on April 10, 2006 from http://www.fda.gov/cdrh/pdf/P980052b.pdf

U.S. Food and Drug Administration. TMJ Implants, Inc. warning letter. February 24, 2004. Retrieved on May 16, 2006 from http://www.fda.gov/foi/warning_letters/g4563d.htm

U.S. Food and Drug Administration. TMJ Implants-A Consumer Informational Update. April 2001. Retrieved on April 10, 2006 from http://www.fda.gov/cdrh/consumer/tmjupdate.html

U.S. Food and Drug Administration. TMJ Implants, Inc. partial temporomandibular joint replacement system. Summary of safety and effectiveness. Retrieved on April 10, 2006 at http://www.fda.gov/cdrh/pdf/P000035b.pdf

U.S. Food and Drug Administration. TMJ Implants, Inc. Total temporomandibular joint replacement system. Summary of safety and effectiveness. Retrieved on April 10, 2006 from http://www.fda.gov/cdrh/pdf/p000023.html

Specialty Matched Consultant Advisory Panel – 5/2007

Policy retitled: Temporomandibular Joint Dysfunction

Specialty Matched Consultant Advisory Panel- 11/2009

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 6/10/2010

Specialty Matched Consultant Advisory Panel 10/2011

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 7/14/2011

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 7/12/2012

Specialty Matched Consultant Advisory Panel 10/2012

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 7/11/2013

Specialty Matched Consultant Advisory Panel 10/2013

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 7/10/2014

Specialty Matched Consultant Advisory Panel. 10/2014

Medical Director Review 10/2014

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 7/9/15

Specialty Matched Consultant Advisory Panel 10/2015

Medical Director Review 10/2015

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 2/11/16

American Association for Dental Research (AADR). AADR Policy Statements: Temporomandibular disorders (TMD). 1996 (revised 2010, reaffirmed 2015). Available at: http://www.iadr.org/AADR/About-Us/Policy-Statements/Science-Policy#TMD

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 2/9/2017

American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. 2001; Available at http://astmjs.org/final%20guidelines-04-27-2005.pdf.

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 2/8/2018

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 2/14/2019

Specialty Matched Consultant Advisory Panel 10/2020

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 2/13/2020

Specialty Matched Consultant Advisory Panel 10/2021

BCBSA Medical Policy Reference Manual [Electronic Version] 2.01.21, 5/2021

Medical Director Review 10/2021

Medical Director Review 1/2022

Sit RW, Reeves KD, Zhong CC, et al. Efficacy of hypertonic dextrose injection (prolotherapy) in temporomandibular joint dysfunction: a systematic review and meta-analysis. Sci Rep. Jul 19 2021; 11(1): 14638. PMID 34282199

Specialty Matched Consultant Advisory Panel 10/2022

Medical Director Review 10/2022

Specialty Matched Consultant Advisory Panel 10/2023

Medical Director Review 10/2023

Specialty Matched Consultant Advisory Panel 10/2024

Medical Director Review 10/2024

Policy Implementation/Update Information

From policy entitled: Temporomandibular Joint Dysfunction (TMJD) Treatment

1/96 Original policy issued

8/99 Adjustments in Range of Motion of the TMJ. Arthroscopy of TMJ policy archived.

9/99 Reformatted, Description of Procedure or Service changed, Medical Term Definitions added.

10/00 Oral Surgery Consultant Panel

12/99 Medical Policy Advisory Group

10/00 System coding changes.

11/00 Phrase “unless contraindicated” added concerning physical therapy under When TMJ Dysfunction is covered in the TMJ surgery section. Criteria renumbered for clarity in the Short term physical therapy and occlusal splints section of when TMJ is covered.

5/01 Specialty Matched Consultant Advisory Panel review (5/2001). No change to policy.

10/03 Specialty Matched Consultant Advisory Panel review (5/30/2003). No changes to criteria. Typos corrected. Revised Benefits Application and Billing/Coding sections. Code DM295 removed from Billing/Coding section (no longer a valid code).

6/2/05 Specialty Matched Consultant Advisory Panel review – 5/13/05. No changes to criteria.

4/10/06 Added CPT code 21010 to Billing/Coding section.

6/5/06 Additional information added to “Description” section. Under “When Covered”, added: (C.4.a&b.) C.4.) Arthrotomy with total prosthetic joint replacement using the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis™ - This procedure is indicated for reconstruction of the TMJ for treatment of end-stage TMJ disease, when no other viable therapeutic alternatives are available. A.) Patients should be considered if they have one or more of the following conditions: Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment, recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment, failed tissue graft, failed alloplastic joint reconstruction, loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion. B.) Total prosthetic joint replacement should not be used for patients with one or more of the following conditions: Active or suspected infections in or about the implantation site, uncontrollable masticatory muscle hyperfunction (clenching or grinding) which may lead to overload and loosening of screws, known allergy to any of the component materials. (F. Arthrocentesis) reworded: “For the intent of this policy, arthrocentesis for closed [jaw] lock (disc displacement without reduction) is considered advanced conservative management rather than a surgical procedure, and does not need to meet the criteria above.” Under “When not Covered”, added total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™ or partial joint replacement with the TMJ Fossa-Eminence Prosthesis™ are not covered. Both devices are considered investigational and BCBSNC does not cover investigational services. Under “Policy Guidelines”, added: “At the present time, there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and long-term outcomes of the TMJ Fossa-Eminence/Condylar Prosthesis System™ for total joint replacement or the TMJ Fossa-Eminence Prosthesis™ for partial joint replacement. (Refer to separate policy number MED1263, Investigational (Experimental) Services.)”.Under Billing/Coding/Physician Documentation, added: “In addition to medical records, a letter of medical necessity is required for all requests for TMJ surgery and should include a detailed history of the condition, diagnostic imaging results and documentation of prior medical and surgical treatment.” Key words, medical term definitions and reference sources added. Notification given 6/5/06. Effective date 8/7/06. (pmo)

6/18/07 Specialty Matched Consultant Advisory Panel review. No changes to criteria. Reference source added. (pmo)

12/31/07 Under “When Covered” added “Therapeutic manipulation of the TMJ requiring anesthesia (i.e., general or monitored anesthesia care) is covered for reduction of fracture or dislocation of the TMJ. Other indications will be reviewed on an individual consideration basis.” Under “Billing/Coding” added new CPT code 21073 effective January 1, 2008. (pmo)

See Also: Orthognathic Surgery Policy

Policy retitled: Temporomandibular Joint Dysfunction (TMJD)

6/22/10 Policy Number(s) removed (amw)

10/26/10 CPT code 21116 (injection procedure for TMJ arthrography) added to “Billing/Coding”section. Additional information added to the Description section. Under “When Covered” Section B: MRI is considered medically necessary changed to may be considered medically necessary; Section C. TMJ Surgery added pharmacological treatment to criteria for medical necessity; Section D. Added arthroscopic coverage criteria. Under “When Not Covered” added Acupuncture as not covered/investigational. Also added Arthroscopy of the TMJ for purely diagnostic purposes is not covered. Specialty Matched Consultant Advisory Panel 1/2010. Reviewed with Senior Medical Director 8/2010. References added. (lpr)

11/22/11 Extensive revisions, renumbering and bulleting under “When Not Covered and Covered Sections.” Under “When Not Covered” section added: ultrasound imaging and sonogram. Removed statement “Braces and orthodontic treatment of TMJD are considered dental therapy and are not eligible under medical benefits” from Policy section. Specialty Matched Consultant Advisory Panel 10/26/2011. (lpr)

2/26/13 Under “When Not Covered” added hyaluronic acid, and low level laser therapy as non surgical investigational indications. Under “When Covered” C.2.a. added arthrocentesis to covered surgical treatments. Reference added. Notification given 2/26/13 for effective date 5/28/13. (lpr)

9/10/13 Updated Regulatory Status. Under “When Not Covered” section #2 Diagnostic Procedures: added joint vibration analysis as investigational indication for diagnostic procedure. Under “When Covered” section B. Non-Surgical Treatments: added Intra-oral removable prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment) as medically necessary indication. Removed reference to low level laser therapy under Policy Guidelines section. Reference updated. Medical director review 7/2013. (lpr)

11/12/13 Specialty Matched Consultant Advisory panel review 10/21/2013. No changes to policy statement. (lpr)

9/9/14 Reference added. No changes to policy statement. (lpr)

11/11/14 Specialty Matched Consultant Advisory panel review 10/2014. Medical Director Review 10/2014. No changes to policy statement. (td)

12/30/14 Added CPT codes 20606 and 20611 to the Billing/Coding section effective 1/1/15. (td)

10/1/15 Description section updated. References updated. Policy intent remains the same. (td)

11/24/15 Specialty Matched Consultant Advisory panel review 10/29/2015. Medical Director Review 10/2015. Policy intent remains unchanged. (td)

8/30/16 When Covered and Not Covered sections reformatted. Added the following to the When TMJD is Covered section, item B: non-surgical treatments “Short term physical therapy [is covered] when administered by a licensed physical therapist.” (an)

9/20/2016 Item 3 in the non-covered section updated to include an additional investigational treatment. Statement now reads: The following non-surgical treatments are considered investigational in the treatment of TMJ dysfunction: Alpha-Stim. Added CPT code 21089. (an)

11/22/16 Specialty Matched Consultant Advisory Panel review 10/26/2016. No change to policy statement. (an)

1/27/17 Added trigger point/tender point injections to the list of investigational, non-surgical treatment for TMJ. Updated Policy Guidelines section. (an)

11/10/17 Description section updated. References added. Specialty Matched Consultant Advisory Panel review 10/25/2017. No change to policy statement or coverage criteria. (an)

4/13/18 Changed “prosthetic” to “orthotic” in the When Covered section, item B. (an)

11/9/18 Minor addition to Description Section. Additions to the When Evaluation and Treatment of TMJD is Not Covered section: Item 2 Diagnostic Procedures: transcranial or lateral skull x-rays, standard dental radiographic procedures, range of motion measurement. Item 3 Non-Surgical Treatments: orthodontic services, dental restoration/prostheses, acupuncture. Policy Guidelines section updated. References added. Specialty Matched Consultant Advisory Panel review 10/24/2018. (an)

10/29/19 Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement. (eel)

11/10/20 Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement. (eel)

5/4/21 Billing/Coding/Physician Documentation information section updated- added codes D7880 and D7881, added the following: “Code 21089 should not be reported for orthotic to treat temporomandibular joint dysfunction. This is not an appropriate code because an orthotic or splint for treatment of temporomandibular joint disease is not an “unlisted maxillofacial prosthetic procedure.”. Reference added. Medical Director review. Policy noticed 5/4/2021 for effective date 7/13/2021. (bb)

11/2/21 References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement. (tt)

2/8/22 Billing/Coding/Physician Documentation information section updated. Added code 21299 to the following statement: Codes 21089 and 21299 should not be reported for orthotic to treat temporomandibular joint dysfunction. This is not an appropriate code because an orthotic or splint for treatment of temporomandibular joint disease is not an “unlisted maxillofacial prosthetic procedure.” Medical Director review 1/2022. (tt)

11/1/22 Minor updates to description for clarity. Regulatory status updated. Related policies added. Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 10/2022. Medical Director Review 10/2022. No change to policy statement. (tt)

11/7/23 Benefits application section updated for clarity. When not covered updated for clarity. Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. (tt)

10/30/24 Updated When Covered section #2b to include “muscle relaxant medications”. Updated When Not Covered #3 to include “Botulinum Toxin Injections”. References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. Added S3900 to billing/coding section. Updated When Not Covered section #3 to include Botulinum Toxin Injections. (tt)