Clinical UM Guideline
|Guideline #:||CG-SURG-09||Current Effective Date:||01/01/2015|
|Status:||Reviewed||Last Review Date:||11/13/2014|
This document addresses temporomandibular joint (TMJ) and related musculoskeletal structure disorders commonly called temporomandibular disorders (TMD), a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, and craniomandibular disorder (CMD).
Note: Please refer to the following documents for additional information concerning related topics:
Nonsurgical treatments considered medically necessary for temporomandibular disorders include the following:
Surgical procedures considered medically necessary for temporomandibular disorders when criteria A and B listed below are met include the following:
Criteria A and B:
Not Medically Necessary:
Nonsurgical treatments considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:
Surgical procedures considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:
The following procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|Including, but not limited to, the following:|
|20605||Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance|
|20606||Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting|
|21010||Arthrotomy, temporomandibular joint|
|21050||Condylectomy, temporomandibular joint (separate procedure)|
|21060||Meniscectomy, partial or complete, temporomandibular joint (separate procedure)|
|21073||Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21116||Injection procedure for temporomandibular joint arthrography|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|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|
|29800||Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)|
|29804||Arthroscopy, temporomandibular joint, surgical|
|D7810||Open reduction of dislocation|
|D7820||Closed reduction of dislocation|
|D7830||Manipulation under anesthesia|
|D7850||Surgical discectomy, with/without implant|
|D7871||Nonarthroscopic lysis and lavage|
|D7873||Arthroscopy- surgical: lavage and lysis of adhesions|
|D7874||Arthroscopy- surgical: disc repositioning and stabilization|
|D7875||Arthroscopy- surgical: synovectomy|
|D7876||Arthroscopy- surgical: discectomy|
|D7877||Arthroscopy- surgical: debridement|
|D7880||Occlusal orthotic appliance|
|D7899||Unspecified TMD therapy, by report|
|D9940||Occlusal guards, by report|
|D9950||Occlusion analysis- mounted case|
|D9951||Occlusal adjustment- limited|
|D9952||Occlusal adjustment- complete|
|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|
|S8262||Mandibular orthopedic repositioning device, each|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|524.50-524.59||Dentofacial functional abnormalities|
|524.60-524.69||Temporomandibular joint disorders|
|ICD-10 Procedure||[For dates of services on or after 10/01/2015]|
|0RBC0ZZ||Excision of right temporomandibular joint, open approach|
|0RBC3ZZ||Excision of right temporomandibular joint, percutaneous approach|
|0RBC4ZZ||Excision of right temporomandibular joint, percutaneous endoscopic approach|
|0RBD0ZZ||Excision of left temporomandibular joint, open approach|
|0RBD3ZZ||Excision of left temporomandibular joint, percutaneous approach|
|0RBD4ZZ||Excision of left temporomandibular joint, percutaneous endoscopic approach|
|0RQC0ZZ-0RQC4ZZ||Repair right temporomandibular joint [includes codes 0RQC0ZZ, 0RQC3ZZ, 0RQC4ZZ]|
|0RQD0ZZ-0RQD4ZZ||Repair left temporomandibular joint [includes codes 0RQD0ZZ, 0RQD3ZZ, 0RQD4ZZ]|
|0RSC04Z-0RSCXZZ||Reposition right temporomandibular joint [includes codes 0RSC04Z, 0RSC0ZZ, 0RSC34Z, 0RSC3ZZ, 0RSC44Z, 0RSC4ZZ, 0RSCX4Z, 0RSCXZZ]|
|0RSD04Z-0RSDXZZ||Reposition left temporomandibular joint [includes codes 0RSD04Z, 0RSD0ZZ, 0RSD34Z, 0RSD3ZZ, 0RSD44Z, 0RSD4ZZ, 0RSDX4Z, 0RSDXZZ]|
|0RUC07Z-0RUC4KZ||Supplement right temporomandibular joint [includes codes [0RUC07Z, 0RUC0JZ, 0RUC0KZ, 0RUC37Z, 0RUC3JZ, 0RUC3KZ, 0RUC47Z, 0RUC4JZ, 0RUC4KZ]|
|0RUD07Z-0RUD4KZ||Supplement left temporomandibular joint [includes codes 0RUD07Z, 0RUD0JZ, 0RUD0KZ, 0RUD37Z, 0RUD3JZ, 0RUD3KZ, 0RUD47Z, 0RUD4JZ, 0RUD4KZ]|
|ICD-10 Diagnosis||[For dates of services on or after 10/01/2015]|
|G44.89||Other headache syndrome|
|M19.91||Primary osteoarthritis, unspecified site|
|M26.50-M26.59||Dentofacial functional abnormalities|
|M26.60-M26.69||Temporomandibular joint disorders|
|S03.0XXA-S03.0XXS||Dislocation of jaw [includes codes S03.0XXA, S03.0XXD, S03.0XXS]|
Temporomandibular disorders (TMD) is a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndromes, and craniomandibular disorder (CMD) that includes a variety of medical and dental conditions involving the masticatory muscles and the temporomandibular joint, as well as contiguous tissue components.
The most frequent presenting symptom associated with TMD is pain, usually localized in the muscles of mastication, the preauricular area, and/or the TMJ, which may be related to trauma. (such as a blow to the face), inflammatory or degenerative arthritis, or by the mandible being pushed back towards the ears whenever the individual chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening the mouth normally. Other common complaints reported by individuals include earache, headache, and facial pain. Individuals may also have limited or asymmetric jaw movement and joint sounds that are usually described as clicking, popping, grating, or crepitus in the TMJ.
In 2012, the American Academy of Oral and Maxillofacial Surgeons (AAOMS) issued a Parameters of Care (5th edition) which provided the following:
Temporomandibular joint (TMJ) surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection…Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient. (AAOMS, 2012)
Conservative therapy is the mainstay in treating TMD. This therapy may include behavioral change, oral medications for pain, anti-inflammatory injections, and orthotic devices. Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. According to the National Institute of Dental and Craniofacial Research (NIDCR), there are no standards to identify people who would most likely benefit from surgery (NIDCR, 2010). A review of available published evidence regarding the safety and efficacy of various medical and surgical treatment modalities for TMJ revealed inconsistent methodologies in study design and no significant benefit of one treatment over another, in terms of improved clinical outcomes (Fricton, 2010; List, 2010; Schiffman, 2007; Truelove, 2006).
Several devices that have obtained pre-market approval/clearance (PMA) from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD include, but are not limited to, the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis (TMJ Concepts, Camarillo, CA); the TMJ Partial Temporomandibular Joint Replacement System, TMJ Fossa-Eminence Prosthesis System™ and the TMJ Patient Specific Fossa-Eminence Prosthesis System™ (TMJ Implants, Inc., Golden, CO); and the Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation [formerly Walter Lorenz Surgical, Inc.,], Jacksonville, FL). The FDA-approved labeling for each of these devices has similar indications, however, to date, the published evidence to support safety, efficacy, and durability of clinical outcomes has been limited.
Analgesics: Medications that provide pain relief.
Arthroplasty: Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.
Behavioral therapy: Therapy aimed to help people examine those behaviors and emotions that have a negative impact on their lives and make a conscious effort to bring about positive changes.
Craniomandibular disorder (CMD): A dental term used to describe diseases or disorders of the muscles of the head and neck, with special reference to the masticatory (chewing) muscles.
Disc: Shortened terminology for an intervertebral disc or a TMJ disc; a disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones.
Mandible: Bone of the lower jaw.
Meniscus: A cartilage pad between the two joint surfaces within the TMJ, acting as a smooth surface for the joint to move on.
Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.
Physical therapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help individuals regain or improve their physical abilities.
Temporal bone: A large irregular bone situated at the base and side of the skull, connected with the mandible via the TMJ.
Temporomandibular joint (TMJ): Joint that hinges the mandible to the temporal bone of the skull; one of the most frequently used joints in the entire body, moving whenever a person eats, drinks, or talks.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
TheraBite® Jaw Motion Rehab System™
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis
TMJ Fossa-Eminence Prosthesis System
Total Temporomandibular Joint (TMJ) Replacement System
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||11/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. No change in criteria. The Discussion and References sections were updated. Updated Coding section with 01/01/2015 CPT changes.|
|Reviewed||11/14/2013||MPTAC review. No change in criteria. The Discussion section and References were updated.|
|Reviewed||11/08/2012||MPTAC review. No change in criteria. References were updated.|
|Reviewed||11/17/2011||MPTAC review. No change in criteria. The Discussion and References were updated.|
|Revised||11/18/2010||MPTAC review. Revised Subject of document to: Temporomandibular Disorders. Clarified wording throughout the Clinical Indications, changing 'temporomandibular dysfunction' to 'temporomandibular disorders.' Revised medically necessary criteria for surgical intervention specific to the age requirement for documented radiograph proof of completion of skeletal growth as follows: "Completion of skeletal growth for individuals under age 18 with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Note: individuals age 18 and older do not require this documentation)." Alphabetized, formatted and reordered document Clinical Indications without additional revisions to the document criteria. Updated Description, Coding, Discussion, Definitions, and References.|
|10/01/2010||Updated Coding section with 10/01/2010 ICD-9 changes.|
|Reviewed||11/19/2009||MPTAC review. Updated References and Coding.|
|Reviewed||11/20/2008||MPTAC review. Updated Discussion and References.|
|Reviewed||11/29/2007||MPTAC review. Updated References and Coding to include 01/01/2008 CPT changes.|
|Reviewed||12/07/2006||MPTAC review. Updated References.|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Anthem Northeast (Maine)||None||BD||TMJ (Temporomandibular Joint Syndrome) Benefit Detail|
|Anthem Midwest||08/06/2004||MA-037||Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ, Craniomandibular Disorder (CMD)|
|WellPoint Health Networks,|
|Temporomandibular Joint Arthroplasty|