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Policy No:  68

Originally Created: 03/01/1997

Section: Miscellaneous

Last Reviewed:  01/01/2019

Last Revised:  01/01/2019

Approved: 01/01/2019

Effective:  01/01/2019

 

Description

Temporomandibular Joint Dysfunction (TMD) is a condition that may be characterized by one or more of the following symptoms: grating or grinding sensation, pain on or about the external auditory meatus on palpation, and stiffness and locking of the jaw. The actual joint pathology may involve the ligaments, capsule (meniscus) or osseous structures and can result from either extrinsic or intrinsic factors leading to condylar displacement, injury of the meniscus, injury of the ligaments or osteoarthritis of the condyle and/or fossa.  Headaches are not synonymous with internal derangement of the TMJ or with TMD, therefore headaches are not covered unless there is documentation of symptoms or signs of internal derangement and the above criteria are met.

Policy/criteria

Procedure is in accordance with generally accepted standards of dental practice.

Administrative guidelines

In the review of procedures related to the diagnosis of Temporomandibular Joint Dysfunction (TMD), there must be documentation of symptoms other than muscle soreness in the area and/or headache. Headache or muscle soreness, without other symptoms, is not an indication that TMD pathology is present. Common symptoms associated with TMD are: crepitus, joint pain, clicking, limited opening of the mouth, limitation of swallowing and chewing, or locking of the joint.

Procedure
Description
Guideline
Panoramic Radiograph A radiological system that utilizes two axes rotation to obtain a panoramic view of the dental arches and their associated structures. Allow panorex for the diagnosis of TMD syndrome.
Tomograms

Process tomograms with the diagnosis of TMD if the clinical symptoms of TMD are present and non-surgical conservative treatment for bruxism and malocclusion have failed. Indications for tomograms include:

  • pain specific to the joint,
  • crepitus,
  • evidence of severe meniscule condylar displacement,
  • limitation of motion and persistent pain after treatment.
Allow if pain persists after treatment.
Tomograms (continued) Includes full tomographic studies which may involve eleven films

The maximum allowable includes all views as one study:

  • 1 sub-mental view (SMV)
  • 3 sagittal views each side teeth closed
  • 1 sagittal view each side with maximum opening
  • 1 AP view
  • 1 trans-orbital or trans-maxillary view
Arthograms

An invasive x-ray study of the TMJ. It is the test to determine perforations in the disc, adhesions and dynamic function.
Indications for arthrogram include:

  • suspected adhesions of the meniscus,
  • suspected perforations of the meniscus,
  • presence of joint noises,
  • pain and failure of conservative therapy,
  • meniscus not visible on CT or MRI,
  • when CT and MRI do not correlate with the symptoms and dynamic study of the meniscus is needed.
Allow for TMD diagnosis.
Transcranial x-rays These x-rays must be used to document the relationship between the condyle and the articular disc, and their relationship to the cranial fossa. X-ray shows the gross pathology during the diagnosis of TMD disorders. Usually there are two films taken; one with jaw open and one with jaw close.  
Magnetic Resonance Imaging (MRI)

MRI is very useful in the diagnosis of TMD syndrome in visualizing the joint and is less invasive than the arthrogram.

MRI is not effective in diagnosing a tear or perforation of the disc or adhesion of the disc.

Indications for MRI include:

  • arthrogram failed to show TMJ disease exists and symptoms are present,
  • suspected neoplasms of the joint and post surgical complications.
MRI is an allowed procedure.
CAT Scan CAT Scan should be performed when all other forms of testing have been negative for TMD and symptoms continue to persist. By report, allow when all sources of pain have been ruled out by customary means and pathology outside the joint is suspected.
Cephalogram Cephalometric x-rays taken of the jaws and skull for the purpose of taking measurements used in oral surgery and orthodontics, and include scientific measurements of the cranium and the facial bones. No benefit.
Full mouth x-rays Full mouth x-rays Full mouth xrays are not medically necessary.

 

Diagnostic procedures - process to TMD benefits

The following diagnostic procedures (non-surgical), conservative therapy may consist of pain medication, anti-inflammatory medications, physical therapy (PT), self-applied hot and cold packs, TENS manipulation, splint therapy, etc.

Procedure
Description
Guideline
Physical Therapy (PT) Approved service for the treatment of TMD. Follow the PT guidelines. Dentists are eligible to do PT on and around the cervical region and facial muscles, head and neck.
Manipulation of the jaw For the treatment of TMD has not been determined to be medically effective. EXCEPT when there is an acute traumatic dislocation of the joint and a reduction is performed under anesthesia. Accident benefits may be applied, using CPT codes 21480 and 21485.  
TENS TENS units are not considered medically necessary to control TMD pain; therefore not eligible as DME. TENS treatment and ultrasound treatment by the PT or dentist are considered medically effective; therefore eligible for benefits according to contract language and limitations.
Electromyograph (EMG) Used to measure the bioelectric activity in the muscle and indicates muscle spasm. It has not been found to directly impact the diagnosis or the treatment of the TMD condition. EMG is to be denied as investigational since medical necessity not established.
Mandibular Kineosiography (MKG) This instrument measures movement of the mandible in three dimensions simultaneously and records the movement photographically for permanent records. It documents craniomandibular dysfunction. This procedure has not been proven to have a direct effect on the diagnosis or treatment of TMD. Deny MKG as investigational since medical necessity not established.
Acupuncture Acupuncture is appropriate for the diagnosis of Myofacial Pain. It is not appropriate for the diagnosis of internal derangement of TMD syndrome without the additional diagnosis of myofacial pain syndrome. Deny as medical effectiveness not established.
Manual assisted exerciser Is a device providing manually assisted exercise during which mandibular motion is guided along a physiologically correct pathway. The device is used at home as a supplement for PT in the early post-operative period. The device is a one-time purchase for each individual patient. Manual assisted exerciser is considered to be medically appropriate for the post-operative period following surgical procedures of the TMD. It may be used for the immediate post-operative period.
Continuous passive motion Usually performed in the immediate post-operative period has not been proven to be medically necessary effective in the post-operative period. Not eligible for benefits.

 

Arthroscopy procedures - process to TMD benefits

The following are arthroscopy procedures; arthroscopy is an invasive procedure using an arthoscope and can be a diagnostic or surgical procedure.

Procedure
Description
Guideline
Arthroscopy, diagnostic:

Allowed when other forms of testing have been inconclusive. If there is another arthoscopic procedure, it is considered incidental. If diagnostic arthroscopy precedes an open arthrotomy, it is considered a secondary procedure and will be processed with multiple procedure guidelines.

 

 

By report. Indications for arthroscopy surgery include:

  • Anterior disc displacement – without reduction, with pain.
  • Anterior disc displacement – with reduction, with pain, with deformed disc.
  • Anterior disc displacement – with reduction, with pain, young patient with mandibular dysfunction.
  • Fibrous adhesions in the upper or lower joint compartment.
  • Normal mandibular function, but with disc perforation, with or without osteoarthritic changes.
  • Foreign body visible on x-rays.
Arthroscopy, surgical: Should be attempted only after other forms of non-surgical therapy have failed. The procedure will be by report.
Arthroscopy, surgical assistant:   Deny as medical necessity not established.
Arthroscopic lysis of adhesions or debridement, and lavage:   Deny as incidental if performed in conjunction with another arthroscopic procedure or open surgical procedure.
Arthroscopic repair or reconstruction of the meniscus/ disc:   By report, to establish medical necessity. Referral should be accompanied by the operative report.

 

Surgical intervention - process to TMD benefits

Surgical intervention to treat TMD may include arthroplasty, coronoidectomy, meniscectomy, condylectomy, joint or articular disc replacement.

Procedure
Description
Guideline
Arthroplasty:

Indications for arthroplasty include:

  • Displaced or torn meniscus.
  • Presence of spurs, necrosis of the condyle; or arthritic deterioration.
  • Failure of conservative therapy over at least 6 months; positive arthrogram or MRI.
  • Failure of medical treatment and evidence of severe joint disease.
  • Ankylosis present.
By report: All documentation needed for review should include reports from all results of testing performed, conservative treatment, history and physical and operative reports from previous procedures performed on the TMJ.
Meniscectomy, disc plication, condylectomy: Are all considered incidental to the arthroplasty. If performed individually without the arthroplasty they may be reimbursed at full maximum allowable. CPT defines these codes "separate procedure." Deny if billed in combination with other codes for the same joint.
Coronoidectomy: Coronoidectomy is usually performed through a separate incision from the arthroplasty. This incision is made in the oral cavity. Bilateral procedure will be reviewed and processed using the multiple procedure guidelines.
Replacement of the articular disc/meniscus: Articular disc removal is determined at the time of arthroplasty. All replacement grafts for the articular disc of the TMJ will be included in the arthroplasty, therefore, not eligible for additional benefits.
Total joint replacement: They must be FDA approved if they are a device. Autografts for total joint replacement must be published and reviewed in peer-reviewed journals and be in accordance with accepted medical practice in the community. All total joint replacement must be pre-authorized.
Microvascular second metatarsophalangeal total joint transplant: Consists of removing the entire second metatarsal and phalangeal joint for transplantation and reconstruction of the TMJ. A microvascular anastamosis is performed, attaching the dorsal pedis artery to a facial artery and veins. This procedure is considered experimental and investigational; therefore not eligible for benefits.

 

Occlusal orthotic devices - process to TMD benefits

The following are occlusal orthotic devices. The types of splints used for splint therapy are diagnostic, repositioning, pain control and bruxism splints. Diagnostic and repositioning splints are used in the diagnosis and treatment of TMD.

Bruxism splints are not directly related to TMD but are very often mistaken as being the same as diagnostic and repositioning splints.

Procedure
Description
Guideline
Diagnostic splint/acute pain reduction in TMD: The diagnostic/acute pain reduction splints are not associated with myofacial pain syndrome (MFPS). This splint is considered medical/TMD. During the use of this splint PT modalities are very often used. Multiple adjustments may be necessary as normal function returns. See review procedure below.
Splint for treatment of MFPS, not TMD: This splint is prescribed for the treatment of myofacial pain not associated with TMD. This splint will be processed as medical.
Repositioning splint:

This splint is designed from the measurements and information gathered. The splint is created AFTER acute pain and spasm have been determined. This splint is more sophisticated in its adjustment. The purpose of the splint is to establish a functional relaxed muscle/jaw relationship for stabilization. If no relief in six months, the patient is to be re-evaluated.

Review procedure for diagnostic and repositioning splints include:

  • Establish medical necessity.
  • Any future replacement splints will be reviewed on an individual consideration if outside the six months global period of a previous splint.
Bruxism splint:

This splint is used to prevent periodontal breakdown, abnormal abrasion of the teeth and pain in the TMD caused by clenching or grinding of the teeth. Occlusal guard in the case of periodontal breakdown must be accompanied by documentation of periodontal treatment. This splint is also used to stop the muscular effects of bruxism (muscle pain and soreness), and would be considered dental.

 

  • When splints are billed as a package with therapy, allow as TMD, according to the contract's TMD benefits.
  • Mandibular repositioning sleep device, snore guard, etc., for sleep apnea: refer to medical policy for sleep apnea.
Dental services which are not eligible for medical benefits under TMD guidelines are:
  • Occlusal equilibration
  • Full mouth reconstruction
  • Dentures
  • Orthodontia
  • Appliance or restoration to increase vertical dimension or restore occlusion.
 

 

List of Valid ADA (Dental) Codes to Use for Processing TMD Claims Billed by a Dental Provider

Codes Number Description
CDT D0160 Detailed and Extensive Oral Evaluation - Problem Focused, By Report
  D0320 Temporomandibular Joint Arthrogram, Including Injection
  D0321 Other Temporomandibular Joint Radiographic Images, By Report
  D0322 Tomographic Survey
  D0330 Panoramic radiographic image
  D0470 Diagnostic Casts (Study Models)
  D7810 Open Reduction of Dislocation
  D7820 Closed Reduction of Dislocation
  D7830 Manipulation Under Anesthesia
  D7840 Condylectomy
  D7850 Surgical Discectomy, With/Without Implant
  D7852 Disc Repair
  D7854 Synovectomy
  D7856 Myotomy
  D7858 Joint Reconstruction
  D7860 Arthrotomy
  D7865 Athroplasty
  D7870 Arthrocentesis
  D7871 Non - Arthroscopic Lysis and Lavage
  D7872 Arthroscopy - Diagnosis, With or Without Biopsy
  D7873 Arthroscopy - Surgical: Lavage and Lysis of Adhesions
  D7874 Arthroscopy - Surgical: Disc Repositioning and Stabilization
  D7875 Arthroscopy - Surgical: Synovectomy
  D7876 Arthroscopy - Surgical: Discectomy
  D7877 Arthoscopy - Surgical: Debridement
  D7880 Occlusal Orthotic Device, By Report
  D7899 Unspecified TMD Therapy, By Report (Please submit with detailed descriptions of services rendered).
  D7991 Coronoidectomy
  D9944, D9945, D9946 Does not apply to TMD. Use D7880
  D9950 Occlusion analysis - Mounted Case

 

Codes

CDT - see above

Disclaimer

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