Surgery Section - Temporomandibular Joint Dysfunction

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description

Temporomandibular joint dysfunction (TMD) may involve dysfunction of the temporomandibular joint (TMJ), muscles of the jaw, or systemic conditions that manifest as problems in these areas. TMJ pathology may involve internal derangement; i.e. disorders of the ligaments, capsule, or disc (meniscus); arthritis, adhesions, ankylosis or myalgias of the masticatory muscles.

Symptoms attributed to TMD are varied and may include, but are not limited to: pain in the TMJ or masticatory muscles; painful clicking sounds in the jaw; restricted movement or locking of the jaw; muscle spasms (trismus); earache; and tinnitus.

Policy/Criteria

Medical, surgical, dental or orthodontic interventions may be considered appropriate in the diagnosis and treatment of TMD as outlined below.

The following diagnostic procedures may be considered medically appropriate for the diagnosis of TMD:

1. Diagnostic radiographs, tomograms, and arthrograms
2. CT scan or MRI (generally CT scans and MRIs are reserved for pre-surgical evaluations)
3. Cephalograms (radiographs of jaws and skull) if major skeletal disharmony exists
4. Pantograms showing the TM joint
5. Diagnostic arthroscopy when other forms of testing have been inconclusive

The following diagnostic procedures are considered investigational in the diagnosis of TMD; as the scientific evidence does not permit conclusions concerning the effect of these procedures on health outcomes:

1. Electromyography (EMG), including surface EMG
2. Kinesiography
3. Thermography
4. Neuromuscular junction testing
5. Somatosensory testing
6. Sonogram (ultrasonic Doppler auscultation)
7. Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMD
8. Muscle testing
9. Standard dental radiographic procedures
10. 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 TMD

Note: Range of motion measurements are an integral part of the clinical exam for TMD and as such are not separately reimbursable.

The following non-surgical treatments may be considered medically appropriate in the treatment of TMD:

1. Custom-made intra-oral removable prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment)
2. Pharmacological treatment (such as anti-inflammatory, muscle relaxant, and analgesic medications)
3. Ultrasound
4. Devices to promote jaw range of motion or development and/or rehabilitation of jaw muscles, when used after surgery, or specifically in cases of fibrosis when used preoperatively.
5. Physical therapy, including diathermy, infrared, and heat and cold treatment, and manipulation

The following non-surgical treatments are considered investigational in the treatment of TMD, as the scientific evidence does not permit conclusions concerning the effect of these procedures on health outcomes.

1. Electrogalvanic stimulation (EGS)
2. Iontophoresis
3. TENS (transcutaneous electrical nerve stimulation)
4. PENS (percutaneous electrical nerve stimulation)

Orthodontic services and dental restorations/prostheses are occasionally utilized to correct occlusion and/or tooth alignment in the overall treatment plan of TMD. However, dental and orthodontic services are not a medical benefit for the treatment of TMD unless specifically listed as a medical benefit in the member contract.

The following surgical treatments may be considered medically appropriate in the treatment of TMD:

1. Arthrocentesis
2. Manipulation for reduction of fracture or dislocation of the condyle or for lysis of fibrosis limiting condylar translation
3. Therapeutic arthroscopic surgery in patients with objectively demonstrated (by diagnostic arthroscopy or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed non-surgical treatment (see exceptions below).
4. Open surgical procedures including, but not limited to, arthroplasties, condylectomies, meniscus or disc plication and disc removal in patients who have failed non-surgical treatment (see exceptions below). TMJ arthroplasty with prosthetic implants may be considered for FDA approved prostheses only.

It may be medically necessary to bypass non-surgical treatments in certain severe conditions of the TMJ.

1. Due to the severity of the condition, arthroplasty may be medically necessary for the following:
   1. Painful advanced TMJ degenerative joint disease or necrosis of the condyle
   2. Displaced or torn meniscus
   3. Fibrous or bony ankylosis of TMJ
   4. Presence of TMJ Teflon-Proplast implants symptomatic or non-symptomatic
   5. Documented failure of TMJ prosthetic replacement devices

Arthroplasty of the TMJ with microvascular metatarsal joint graft or any non-FDA approved prosthetic joint device is considered investigational due to a lack of scientific evidence concerning health outcomes. Due to the frequently changing status of TMJ prosthetic devices it is recommended that the FDA Web site be consulted for each new implant request in patients meeting the above criteria for surgical treatment.

References

1. BlueCross and BlueShield Association Medical Policy Reference Manual, Policy No. 2.01.21
2. The FDA Web site information on TMJ Devices: www.fda.gov/cdrh/fr/tmj.html (Verified 11/03/2003)
3. Barandrick, et al. Failure rate of repetitive temporomandibular joint surgical procedures. J Oral Maxillofac Surg 1992:50(suppl 3);145
4. Marbach, Joseph. Temporomandibular Pain and Dysfunction Syndrome: History, Physical Examination, and Treatment. Rheumatic Diseases Clinics of North America 1996;22(3):477-498
5. Raphael, et al. Evidence-based care of musculoskeletal facial pain: Implications for the clinical science of dentistry. J Am Dent Assoc 1997;128:73-79
6. Dolwick et al. The role of temporomandibular joint surgery in the treatment of patients with internal derangement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83(1):150-5
7. Dierks EJ, Beuhler MJ. Complete replacement of the temporomandibular joint with a microvascular transfer of the second metatarsal-phalangeal joint. Oral and Maxillofacial Surgery Clinics of North America Feb 2000;12(1):139-147
8. Ting Zs, Chang TS, Wang TC, Wand W, Feng SZ. Vascular metatarsophalangeal to ankylosed temporomandibular joint replacement. Annals of Plastic Surgery Dec 1985;15(6):497-500
9. Yih WY, Merrill RG. Pathology of Alloplastic interpositional implants kin the temporomandibular joint. Oral and Maxillofacial Surgery Clinics of North America Dec 1989;1(2):415-426
10. Zhong-Wei C, Meyer VE, Beasley R. The versatile second toe microvascular transfer. Orthopedic Clinics of North America Oct 1981;12(4):827-834

Cross References

None

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