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Medical Policy: 02.01.21
Original Effective Date: October 1995
Reviewed: May 2012
Revised: August 2003
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Temporomandibular joint dysfunction (TMJ), also known as TMD, craniomandibular jaw disorder (CMJ) or craniomandibular disorder (CMD), refers to a group of conditions associated with pain and dysfunction of the masticatory system. Symptoms attributed to TMJ dysfunction are varied and include, but not limited to: clicking sounds in the jaw, headaches, closing or locking of the jaw due to muscle spasm (trismus) or displaced disc, pain in the ears, neck, arms and spine, tinnitus, and bruxism (clenching or grinding of teeth).
The diagnosis of TMJ is largely based upon the symptoms of pain and biologic variables, (e.g. joint sounds, variations from ideal disc position, clicking). These conditions may also be found in large segments of the general populations without evidence of impairment of dysfunction that require treatment.
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Prior Approval:
Not applicable
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Policy:
The following diagnostic procedures for TMJ may be considered medically necessary:
- X-ray, tomograms, arthrograms
- CT scan or MRI
- Cephalograms, pantograms
The following non-surgical treatments may be considered medically necessary:
- Intra-oral reversible prosthetic devices/appliances
- Pharmacological treatment (such as anti-inflammatory, muscle-relaxing, and analgesic medications)
The following surgical treatments may be considered medically necessary:
- Arthroscopic surgery
- Arthroplasty
- Closed or open treatment of dislocation
- Arthrocentesis
- Trigger Joint injection
The following non-surgical treatments performed by physical medicine providers may be considered medically necessary when services are consistent with the Wellmark Physical Medicine Guidelines ( 2.6 MB):
- Electrogalvanic stimulation
- Iontophoresis
- Ultrasound
- Manual therapy
- Osteopathic or chiropractic manipulation
The following diagnostic procedures are considered investigational services for treatment of TMJ:
- EMG
- Kinesiography
- Thermography
- Neuromuscular junction testing
- Somatosensory testing
- Transcranial or lateral skull x-rays
- Sonogram
- Intra-oral tracing or gothic arch tracing
- Muscle testing
- Standard dental radiographic procedures
- Range of motion measurements
- Computerized mandibular scan
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral
- 70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral
- 70332 Temporomandibular joint arthrography, radiological supervision and interpretation
- 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
- 70350 Cephalogram, orthodontic
- 70100 Radiologic examination, mandible; partial, less than 4 views
- 70110 Radiologic examination, mandible; complete, minimum of 4 views
- 29804 Arthroscopy, temporomandibular joint, surgical
- 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
- 21242 Arthroplasty, temporomandibular joint, with allograft
- 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement
- 21480 Closed treatment of temporomandibular dislocation; initial or subsequent
- 21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent
- 21490 Open treatment of temporomandibular dislocation
- 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
- 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
- 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
- 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
- 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- 97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes
- 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
- 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved
- 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions
- 95867 Needle electromyography; cranial nerve supplied muscle(s), unilateral
- 95868 Needle electromyography; cranial nerve supplied muscles, bilateral
- 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
- 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method
- 95927 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
- 93875 Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)
- 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
- 70487 Computed tomography, maxillofacial area; with contrast material(s)
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Selected References:
- National Institutes of Health Technology Assessment Statement- Management of Temporomandibular Disorders- April 1996.
- Iglarsh, ZA Temporomandibular Joint Dysfunction: Presented in the Guide to Physical Therapist Practice as found in Orthopaedic Physical Therapy Clinics of North America Issue on Upper Quadrant: Evidence-Based Description of Clinical Practice (Ed by JJ Godges and GD Deyle) 1999 March 8(1), pp 69—82.
- ECRI. Temporomandibular Articular Disorders: Selected Treatments (TMJ). Plymouth Meeting (PA): Technology Assessment Report. March 2001. 269 p. Available: http://www.ecri.org
- ECRI. Temporomandibular Joint Arthroscopy. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005 March 23. 8 p. (ECRI Hotline Response). Available: http://www.ecri.org
- American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. Available: http://www.astmjs.org/guidelines.htm. Accessed on August 4, 2008.
- Wellmark Physical Medicine Guide ( January 2008 Edition). Wellmark Blue Cross Blue Shield
- ECRI. Efficacy of Treatments for Temporomandibular Joint Disorders. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 October 3. (Hotline Response). Also available: http://www.ecri.org.
- ECRI. Mechanical Stretching Devices (Therabite and Other Devices) for Limited Jaw Mobility. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2011 March 23. (Hotline Response). Also available: http://www.ecri.org.
- Dym, H & Israel, H. Diagnosis and treatment of temporomandibular disorders. Dent Clin North Am 2012 Jan;56(1):149-61.
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Policy History:
Date Reason Action
July 2011 Annual review Policy revised
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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