Medical Policy: 02.01.21 
Original Effective Date: October 1995 
Reviewed: January 2016 
Revised: January 2016 


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. 

 

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) 


Prior Approval:

 

Not applicable


Policy:

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.

 

The following non-surgical treatments are considered investigational for treatment of TMD:

  • Biofeedback
  • 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
  • Ionphoresis
  • Manipulation under anesthesia, outside of dislocation and fracture
  • Dry Needling
  • Neuromuscular Re-education
  • Neuromuscular Dentistry

The following diagnostic procedures are considered investigational services for treatment of TMD:

  • EMG
  • Neuromuscular junction testing
  • Somatosensory testing
  • Muscle testing
  • Standard dental radiographic procedures
  • Range of motion measurements
  • Arthroscopy for diagnosis
  • Joint vibration analysis
  • Thermographic testing
  • Bruxism device (e.g. Bruxoff, Grindcare)

The following surgical treatments are considered medically necessary:

  • Arthrocentesis
  • Arthroplasty
  • Arthroscopy
  • Arthrotomy

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

The following surgical treatments are considered investigational in the treatment of TMJ:

  1. Total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™
  2. Partial joint replacement with the TMJ Fossa-Eminence Prosthesis™

 

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.


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.
  • 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance
  • 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance 
  • 20999 Unlisted procedure, musculoskeletal system, general
  • 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
  • 70250 Radiologic examination, skull; less than 4 views
  • 70260 Radiologic examination, skull; complete, minimum of 4 views
  • 70300 Radiologic examination, teeth; single view
  • 70310 Radiologic examination, teeth; partial examination, less than full mouth
  • 70320 Radiologic examination, teeth; complete, full mouth
  • 76499 Unlisted diagnostic radiographic procedure
  • 77077 Joint survey, single view, 2 or more joints (specify)
  • 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
  • 95851 Range 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
  • 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
  • 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
  • E1399 Durable medical equipment, miscellaneous
  • 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                 

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 External SiteTemporomandibular Articular Disorders: Selected Treatments (TMJ). Plymouth Meeting (PA): Technology Assessment Report. March 2001. 269 p.
  • ECRI External SiteTemporomandibular Joint Arthroscopy. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005 March 23. 8 p. (ECRI Hotline Response).
  • American Society of Temporomandibular Joint Surgeons External SiteGuidelines 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 External SiteEfficacy 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 External Site2011 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 External Site(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.
  • American Dental Association External SiteTemporomandibular (Craniomandibular) Disorders. Practice Parameters. Revised1997. TMJ Association
  • American Society of Temporomandibular Joint Surgeons External SiteGuidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures.
  • Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc. Aug 2012;143(8):847-857. PMID 22855899
  • Sharma S, Crow HC, McCall WD Jr, Gonzalez YM. Systematic review of reliability and diagnostic validity of joint vibration analysis for diagnosis of temporomandibular disorders. J Orofac Pain. 2013;27(1):51-60.
  • National Institute for Health and Clinical Excellence (NICE). Total prosthetic replacement of the temporomandibular joint. Interventional Procedure Guidance 329. London, UK: NICE; December 2009. 

Policy History:

  • January 2016 - Annual Review, Policy Revised
  • January 2015 - Annual Review, Policy Renewed
  • February 2014 - Annual Review, Policy Revised
  • May 2013 - Annual Review, Policy Revised
  • May 2012 - Annual Review, Policy Revised
  • July 2011 - 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.