Medical Policy Manual

Policy/Criteria

Medical and/or surgical intervention may be considered medically appropriate in the treatment of TMJ dysfunction as outlined under Policy Guidelines.

Policy Guidelines

The following diagnostic procedures may be considered medically appropriate in the diagnosis of TMJ dysfunction:

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)

4.

Pantograms (radiographs of maxilla and mandible)

5.

Diagnostic arthroscopy when other forms of testing have been inconclusive

The following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction; 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 TMJ dysfunction)

8.

Muscle testing

9.

Standard dental radiographic procedures

10.

Range of motion measurements

11.

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 TMJ dysfunction)

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

1.

Intra-oral removable prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment)

2.

Pharmacological treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications)

3.

Ultrasound

4.

Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function, 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 TMJ dysfunction, as the scientific evidence does not permit conclusions concerning the effect of these procedures on health outcomes.

1.

Electrogalvanic stimulation

2.

Iontophoresis

3.

TENS (transcutaneous electrical nerve stimulation)

4.

PENS (percutaneous electrical nerve stimulation)

Orthodontic services and dental restorations/prostheses are occasionally utilized in the treatment of TMJ dysfunction. However, such services are generally not a medical benefit of the subscriber contract.

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

1.

Arthrocentesis

2.

Manipulation for reduction of fracture or dislocation of the TMJ or for fibrosis limiting condylar translation

3.

Arthroscopic surgery in patients with objectively demonstrated (by physical examination 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 when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed conservative 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.

A.

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.

Fibrous or bony ankylosis of TMJ.

3.

Presence of TMJ Teflon-Proplast implants.

4.

Documented failure of TMJ prosthetic replacement devices.

B.

Due to the severity of the condition, arthroscopic lysis and lavage may be medically necessary for an acute, anteriorly displaced disk without reduction (acute closed locked) which has failed attempts of manual reduction.

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 website be consulted for each new implant request in patients meeting the above criteria for surgical treatment.

References

1.

The Gray Sheet. October 16, 2000

2.

TMJ Concepts: Patient-Fitted Temporomandibular Joint Reconstruction Prosthesis System product information submitted to the FDA; June 10, 1999.

3.

Barandrick, et al. Failure rate of repetitive temporomandibular joint surgical procedures. J Oral Maxillofac Surg 50(suppl 3) 1992:145.

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.

Rationale for Benefit Administration

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.

Cross References

None

Codes

Number

Description

CPT

21050

Condylectomy, temporomandibular joint

21060

Partial/complete meniscectomy, temporomandibular joint

21240-21242

Arthroplasty, temporomandibular joint code range

29800

Diagnostic arthroscopy, temporomandibular joint

29804

Surgical arthroscopy, temporomandibular joint

70328-70332

Radiologic exam of temporomandibular joint code range (including diagnostic x-rays, arthrograms)

70336

MRI of temporomandibular joint

70350

Cephalogram, orthodontic

70355

Orthopantogram

90844

Individual medical psychotherapy by a physician, approximately 45 to 50 minutes

97010

Application of hot or cold packs

97024

Diathermy

97026

Infrared

HCPCS

L8641

Metatarsal joint implant

L8699

Prosthetic implant, not otherwise specified