Clinical UM Guideline


Subject:Temporomandibular Disorders
Guideline #:  CG-SURG-09Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

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:

Clinical Indications

Medically Necessary:

Nonsurgical treatments considered medically necessary for temporomandibular disorders include the following:

  1. Reversible, removable, intraoral appliances such as removable splints;
  2. Pharmacologic therapy (that is, analgesics, anti-inflammatory drugs, and muscle relaxants);
  3. Physical therapy;
  4. Therapeutic injections.

Surgical procedures considered medically necessary for temporomandibular disorders when criteria A and B listed below are met include the following:

  1. Arthrocentesis;
  2. Arthroscopic surgery;
  3. Manipulation for reduction of fracture or dislocation;
  4. Open surgical procedures, including arthroplasty, condylectomy, disc or meniscus plication, and disc removal when TMD is the result of congenital anomalies, disease, or trauma;
  5. TMJ arthroplasty with prosthetic implants may be considered for U.S. Food and Drug Administration (FDA) approved prostheses only. 

Criteria A and B:
A.  Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by BOTH of the following:

AND

B.  Temporomandibular joint pain or a clinically significant functional impairment, NOT due to a maxillary/mandibular skeletal deformity AND refractory to at least six months of non-surgical treatment to include at least ONE of the following:

Not Medically Necessary:

Nonsurgical treatments considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

  1. Biofeedback;
  2. Dental devices for joint range of motion or for development of muscles used in jaw function;
  3. Dental prostheses (for example, dentures; implants);
  4. Dental restorations (for example, bridgework; crowns);
  5. Electrogalvanic stimulation (EGS);
  6. Iontophoresis;
  7. Occlusal equilibration, bite adjustment, irreversible occlusion therapy;
  8. Orthodontic services such as braces and application of a mandibular advancement repositioning device.

Surgical procedures considered not medically necessary for temporomandibular disorders include, but not limited to, the following:

  1. Dental implants;
  2. Dental restorations;
  3. Extraction of wisdom teeth;
  4. Orthodontic services;
  5. TMJ arthroplasty implants that are not FDA approved. 

Diagnostic Testing:
The following procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

  1. Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning);
  2. Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning);
  3. Electromyography (including percutaneous or surface electrode methods);
  4. Kinesiography;
  5. Somatosensory testing/neuromuscular junction testing;
  6. Sonogram (ultrasonic Doppler auscultation);
  7. Standard dental x-rays;
  8. Thermography;
  9. Transcranial or lateral skull x-ray. 
Coding

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.

CPT 
 Including, but not limited to, the following:
20605Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
21010Arthrotomy, temporomandibular joint
21050Condylectomy, temporomandibular joint (separate procedure)
21060Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
21073Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)
21110Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
21116Injection procedure for temporomandibular joint arthrography
21210Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21240Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242Arthroplasty, temporomandibular joint, with allograft
21243Arthroplasty, temporomandibular joint, with prosthetic joint replacement
29800Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804Arthroscopy, temporomandibular joint, surgical
  
HCPCS 
D7810Open reduction of dislocation
D7820Closed reduction of dislocation
D7830Manipulation under anesthesia
D7840Condylectomy
D7850Surgical discectomy, with/without implant
D7852Disc repair
D7854Synovectomy
D7856Myotomy
D7858Joint reconstruction
D7860Arthrotomy
D7865Arthroplasty
D7870Arthrocentesis
D7871Nonarthroscopic lysis and lavage
D7873Arthroscopy- surgical: lavage and lysis of adhesions
D7874Arthroscopy- surgical: disc repositioning and stabilization
D7875Arthroscopy- surgical: synovectomy
D7876Arthroscopy- surgical: discectomy
D7877Arthroscopy- surgical: debridement
D7880Occlusal orthotic appliance
D7899Unspecified TMD therapy, by report
D9940Occlusal guard, by report
D9950Occlusion analysis- mounted case
D9951Occlusal adjustment- limited
D9952Occlusal adjustment- complete
E1700Jaw motion rehabilitation system
E1701Replacement cushions for jaw motion rehabilitation system, package of 6
E1702Replacement measuring scales for jaw motion rehabilitation system, package of 200
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
76.5Temporomandibular arthroplasty
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
524.50-524.59Dentofacial functional abnormalities
524.60-524.69Temporomandibular joint disorders
784.92Jaw pain
  
ICD-10 Procedure[For dates of services on or after 10/01/2014]
0RBC0ZZExcision of right temporomandibular joint, open approach
0RBC3ZZExcision of right temporomandibular joint, percutaneous approach
0RBC4ZZExcision of right temporomandibular joint, percutaneous endoscopic approach
0RBD0ZZExcision of left temporomandibular joint, open approach
0RBD3ZZExcision of left temporomandibular joint, percutaneous approach
0RBD4ZZExcision of left temporomandibular joint, percutaneous endoscopic approach
0RQC0ZZ-0RQC4ZZRepair right temporomandibular joint [includes codes 0RQC0ZZ, 0RQC3ZZ, 0RQC4ZZ]
0RQD0ZZ-0RQD4ZZRepair left temporomandibular joint [includes codes 0RQD0ZZ, 0RQD3ZZ, 0RQD4ZZ]
0RSC04Z-0RSCXZZReposition right temporomandibular joint [includes codes 0RSC04Z, 0RSC0ZZ, 0RSC34Z, 0RSC3ZZ, 0RSC44Z, 0RSC4ZZ, 0RSCX4Z, 0RSCXZZ]
0RSD04Z-0RSDXZZReposition left temporomandibular joint [includes codes 0RSD04Z, 0RSD0ZZ, 0RSD34Z, 0RSD3ZZ, 0RSD44Z, 0RSD4ZZ, 0RSDX4Z, 0RSDXZZ]
0RUC07Z-0RUC4KZSupplement right temporomandibular joint [includes codes [0RUC07Z, 0RUC0JZ, 0RUC0KZ, 0RUC37Z, 0RUC3JZ, 0RUC3KZ, 0RUC47Z, 0RUC4JZ, 0RUC4KZ]
0RUD07Z-0RUD4KZSupplement left temporomandibular joint [includes codes 0RUD07Z, 0RUD0JZ, 0RUD0KZ, 0RUD37Z, 0RUD3JZ, 0RUD3KZ, 0RUD47Z, 0RUD4JZ, 0RUD4KZ]
  
ICD-10 Diagnosis[For dates of services on or after 10/01/2014]
M26.50-M26.59Dentofacial functional abnormalities
M26.60-M26.69Temporomandibular joint disorders
  
Discussion/General Information

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.

According to the American Society of Temporomandibular Joint Surgeons (ASTMJS) clinical guidelines for Diagnosis and Management of Disorders involving the Temporomandibular Joint and related Musculoskeletal structures (which has not been updated since 2001):

As in any disease, an understanding of the natural course of the disease is necessary to guide treatment.  Most symptoms resolve over time, but a significant percentage requires a year or more to do so. The seriousness of the symptoms also varies greatly. Consideration should be given to treatment options, the time course for resolution of symptoms, their seriousness, and the progressive nature of the disease. Treatment efforts are directed toward: 1) reduction of pain, 2) improvement of dysfunction, 3) slowing the progression of the joint disease. TMJ arthroplasty is usually attempted after all nonsurgical methods of treatment have failed (ASTMJS, 2001).

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.

Definitions

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.

References

Peer Reviewed Publications:

  1. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg. 2007; 36(9):773-782.
  2. 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. 2012; 143(8):847-857.
  3. Ebrahimi A, Ashford BG. Advances in temporomandibular joint reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2010; 18(4):255-260.
  4. Fricton J, Look JO, Wright E, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain. 2010; 24(3):237-254.
  5. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005; 63(8):1174-1179.
  6. Keller EE, Baltali E, Liang X, et al.  Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study.  J Oral Maxillofac Surg. 2012; 70(2):276-288.
  7. Lindenmeyer A, Sutcliffe P, Eghtessad M, et al.  Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review. J Oral Maxillofac Surg. 2010; 68(11):2755-2764.
  8. Linsen SS, Reich RH, Teschke M.  Mandibular kinematics in patients with alloplastic total temporomandibular joint replacement-a prospective study.  J Oral Maxillofac Surg. 2012; 70(9):2057-2064.
  9. List T, Axelsson S. Management of TMD: Evidence from systematic reviews and meta-analyses. J Oral Rehab. 2010; 37(6):430-451.
  10. Manfredini D, Rancitelli D, Ferronato G, Guarda-Nardini L.  Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols.  J Oral Rehabil. 2012; 39(4):245-251.
  11. Marbach, JJ. Temporomandibular pain and dysfunction syndrome: history, physical examination, and treatment. Rheumatic Dis Clin of North Am. 1996; 22(3):477-498.
  12. McKenna SJ. Modified mandibular condylotomy. Oral Maxillofacial Surg Clin N Am. 2006; 18(3):369-381.
  13. McLeod NM, Saeed NR, Hensher R.  Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis.  Br J Oral Maxillofac Surg. 2001; 39(1):63-66.
  14. Park J, Keller EE, Reid KI.  Surgical management of advanced degenerative arthritis of temporomandibular joint with metal fossa-eminence hemijoint replacement prosthesis: an 8-year retrospective pilot study.  J Oral Maxillofac Surg. 2004; 62(3):320-328.
  15. Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007; 86(1):58-63.
  16. Truelove E, Huggins KH, Manci L, Dworkin SF.  The efficacy of traditional, low cost, and non-splint therapies for temporomandibular disorder.  J Am Den Assoc. 2006; 137(8):1099-1107.
  17. 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):171-179.
  18. Widmalm S, Brooks S, Sano T, et al. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol. 2006; 35(5):334-338.
  19. Wolford LM. Factors to consider in joint prosthesis systems. Proc (Bayl Univ Med Cent). 2006; 19(3):232-238.
  20. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of two temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg. 2003a; 61(6):685-690.
  21. Wolford LM, Pitta MC, Reiche-Fishel O. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003b; 32(3):268-274.
  22. Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(6):671-675.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Al-Ani MZ, Davies SJ, Gray RJM, et al. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev. 2009; (1):CD002778. Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002778.pub2/abstract.  Accessed on September 30, 2013.
  2. American Academy of Oral and Maxillofacial Surgery (AAOMS). Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgeons (AAOMS Parcare 2012). 5th ed. AAOMS; 2012.  Available at:  http://www.dds2dds.com/admin/pdfs/parcare_ver5.pdf.  Accessed on September 27, 2013.
  3. American Association of Oral and Maxillofacial Surgeons (AAOMS). Parameters of care for oral and maxillofacial surgery.  Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region.  2008.  Available at:  http://www.aaoms.org/docs/practice_mgmt/impairment_guidelines.pdf.  Accessed on September 30, 2013. 
  4. American Association of Oral and Maxillofacial Surgeons (AAOMS).  Information on TMJ.  Available at:  http://www.aaoms.org/tmj.php.  Accessed on September 30, 2013.
  5. American Association for Dental Research (AADR). Policy Statement: Temporomandibular joint disorders (TMJ).  Adopted 1996; updated 2010.  Available online at: http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465.  Accessed on September 30, 2013.
  6. American Society of Temporomandibular Joint Surgeons (ASTMJS). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Revised 2001. Available at: http://astmjs.org/final%20guidelines-04-27-2005.pdf.  Accessed on September 26, 2013.
  7. de Souza RF, Lovato da Silva CH, Nasser M, et al.  Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012; (4):CD007261.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007261.pub2/abstract.  Accessed on September 30, 2013.
  8. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2008; (1):CD000979.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000979/abstract.    Accessed on September 30, 2013.
  9. Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. 2010; (7):CD006541.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006541.pub2/abstract.  Accessed on September 30, 2013.
  10. National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance 329: Total prosthetic replacement of the temporomandibular joint. London, UK. NICE: December 2009. Available at: http://guidance.nice.org.uk/IPG329. Accessed on September 30, 2013.
  11. National Institutes of Health (NIH). National Institute of Dental and Craniofacial Research (NIDCR). Temporomandibular joint (TMJ) and muscle disorders. Revised March 2010. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/.  Accessed on September 26, 2013.
  12. Rigon M, Pereira LM, Bortoluzzi MC, et al.  Arthroscopy for temporomandibular disorders.  Cochrane Database Syst Rev. 2011; (7):CD 006385.  Available at:  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006385.pub2/abstract.  Accessed on September 30, 2013.
  13. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis System. Summary of Safety and Effectiveness. No. P980052. Rockville, MD: FDA. July 2, 1999. Available at:   http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P980052. Accessed on September 30, 2013.
  14. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Partial Temporomandibular Joint Replacement System; TMJ Fossa-Eminence Prosthesis System and TMJ Patient Specific Fossa-Eminence Prosthesis System.  Summary of Safety and Effectiveness. No. P000035. Rockville, MD:FDA. February 27, 2001. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P000035. Accessed on September 30, 2013.
  15. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Metal-on-Metal Total Temporomandibular Joint Replacement System; TMJ Fossa Eminence/Condylar Prosthesis System. Summary of Safety and Effectiveness. No. P000023. Rockville, MD: FDA. January 5, 2001. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=p000023. Accessed on September 30, 2013.
  16. U.S. Food and Drug Administration (FDA) Premarket Notification Database. Walter Lorenz Total Temporomandibular Joint (TMJ) Replacement System. Summary of Safety and Effectiveness. No. P020016. Rockville, MD: FDA. September 21, 2005. Available at:  http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=7230.  Accessed on September 30, 2013.
  17. White SC, Heslop EW, Hollender LG, et al. Parameters of radiologic care: an official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(5):498-511.
Index

Arthrocentesis, TMJ Dysfunction

Arthroscopy, TMJ Dysfunction

Temporomandibular Joint

TheraBite® Jaw Motion Rehab System™

TMJ

TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis

TMJ Fossa-Eminence Prosthesis System

Total Temporomandibular Joint (TMJ) Replacement System

History
 Status Date

 Action

Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  No change in criteria.  The Discussion section and References were updated.
Reviewed11/08/2012MPTAC review.  No change in criteria.  References were updated.
Reviewed11/17/2011MPTAC review.  No change in criteria.  The Discussion and References were updated.
Revised11/18/2010MPTAC 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.
 10/01/2010Updated Coding section with 10/01/2010 ICD-9 changes.
Reviewed11/19/2009MPTAC review. Updated References and Coding.
Reviewed11/20/2008MPTAC review. Updated Discussion and References.
Reviewed11/29/2007MPTAC review. Updated References and Coding to include 01/01/2008 CPT changes.
Reviewed12/07/2006MPTAC review. Updated References.
Revised12/01/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
 Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

N/A

N/AN/A
Anthem Northeast (Maine)

None

BDTMJ (Temporomandibular Joint Syndrome) Benefit Detail
Anthem Midwest

08/06/2004

MA-037Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ, Craniomandibular Disorder (CMD)
WellPoint Health Networks, Inc.

09/23/2004

Clinical GuidelineTemporomandibular Joint Arthroplasty