Medical Policy: 02.01.21
Original Effective Date: October 1995
Reviewed: January 2015
Revised: January 2015
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.
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.
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.
American Association for Dental Research: A policy statement, revised in 2010
Based on clinical evidence, the AADR strongly recommends that, unless there are specific and justifiable indications to the contrary, treatment of temporomandibular disorder (TMD) patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes, they present much less risk of producing harm (AADR, 2010).
American Society of Temporomandibular Joint Surgeons (ASTJS) Consensus Clinical Guidelines (2001)
Nonsurgical treatment should be considered first for all symptomatic patients with this condition. Recommended treatment options include change in diet, nonsteroidal anti-inflammatory drugs, maxillomandibular appliances, physical therapy, and injections of corticosteroids.
TMJ Association (2012)
Surgical treatments are controversial and should be avoided when possible. There have been no long-term clinical trials to study the safety and effectiveness of surgical treatments for TMD, nor are there criteria to identify people who would most likely benefit from surgery.
Replacement of the temporomandibular joint with an artificial implant should be considered a last resort. When used in patients who have had multiple prior jaw surgeries it may improve function, but studies have shown that it generally does not significantly reduce pain. Before undergoing such surgery on the jaw joint, it is extremely important to get other independent opinions and to fully understand the benefits and risks (TMJ Association website)
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, which is available at http://www.wellmark.com/e_business/provider/prov_guides.htm:
- Manual therapy
- Osteopathic or chiropractic manipulation
The following non-surgical treatments are considered investigational for treatment of TMD:
- Low-load prolonged-duration stretch (LLPS) devices such as the Dynasplint system
- Passive Rehabilitation Therapy such as the Therabite
- Low-level laser Therapy
- Bruxism Monitor
- Manipulation under anesthesia, outside of dislocation and fracture
- Dry Needling
The following diagnostic procedures are considered investigational services for treatment of TMD:
- Neuromuscular junction testing
- Somatosensory testing
- Muscle testing
- Standard dental radiographic procedures
- Range of motion measurements
- Arthroscopy for diagnosis
The following surgical treatments are considered medically necessary:
only when all the following conservative treatments have been unsuccessful in relieving pain of TMD.
- NSAID use for at least 4 weeks
- Corticosteroid injections are ineffective or contraindicated
- Soft diet for at least 3 months
- Orthotic use consistent for at least 3 months
- Physical therapy continuously for a minimum of 3 months
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 21060 Meniscectomy, partial or complete, temporomandibular joint
- 21073 Manipulation of temporomandibular joint, therapeutic, requiring an anesthesia service
- 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
- 21299 Unlisted craniofacial and maxillofacial procedure
- 29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
- 29804 Arthroscopy, temporomandibular joint, surgical
- 64550 Application of surface (transcutaneous) neurostimulator
- 70300 Radiologic examination, teeth; single view
- 70320 Radiologic examination, teeth; complete, full mouth
- 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes
- 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes
- 95867 Needle electromyography; cranial nerve supplied muscle(s), unilateral
- 95868 Needle electromyography; cranial nerve supplied muscles, bilateral
- 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
- 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
- 95851Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)
- 97033- Application of a modality to one or more areas; iontophoresis, each 15 minutes
- S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes
- E0746 Electromyography (EMG), biofeedback device
- E1700 Jaw motion rehabilitation system
- E1701 Replacement cushions for jaw motion rehabilitation system, package of 6
- E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200
- 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.
- ECRI. Temporomandibular Joint Arthroscopy. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005 March 23. 8 p. (ECRI Hotline Response).
- American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. 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).
- 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).
- Dym, H & Israel, H. Diagnosis and treatment of temporomandibular disorders. Dent Clin North Am 2012 Jan;56(1):149-61.
- American Association for Dental Research (AADR). Policy Statement: Temporomandibular joint disorders (TMJ).
- Vos LM, Huddleston Slater JJ, Stegenga B. Lavage therapy versus nonsurgical therapy for the treatment of arthralgia of the temporomandibular joint: a systematic review of randomized controlled trials. J Orofac Pain 2013; 27(2):171-9.
- TMJ Association
Date Reason Action
July 2011 Annual review Policy revised
May 2012 Annual review Policy renewed
May 2013 Annual review Policy revised
February 2014 Annual review Policy revised
January 2015 Annual review Policy revised
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.