![]() | Clinical UM Guideline |
Subject: Temporomandibular Disorders | |
Guideline #: CG-SURG-09 | Publish Date: 01/03/2024 |
Status: Revised | Last Review Date: 11/09/2023 |
Description |
This document addresses treatments for conditions of the temporomandibular joint (TMJ) and related musculoskeletal structures. Such conditions are commonly referred to as temporomandibular disorders (TMD), temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, or craniomandibular disorder (CMD).
Note: Please refer to the following documents for additional information on related topics:
Note:
Clinical Indications |
Medically Necessary:
Intraoral appliances (for example, occlusal splints, bite appliances, and mandibular occlusal repositioning appliances) are considered medically necessary for temporomandibular disorders.
Surgical procedures are considered medically necessary for the treatment of temporomandibular disorders when the following criteria are met (A and B):
Not Medically Necessary:
The following nonsurgical treatments are considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:
Surgical procedures for temporomandibular disorders are considered not medically necessary when the above criteria are not met.
The following diagnostic tests and procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:
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.
When services are Medically Necessary:
HCPCS |
|
D7880 | Occlusal orthotic device, by report [when specified as removable TMJ splints, mandibular occlusal repositioning appliances] |
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ICD-10 Diagnosis |
|
M26.601-M26.69 | Temporomandibular joint disorders |
When services may be Medically Necessary when criteria are met:
CPT |
|
| 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 [when specified as temporomandibular joint aspiration] |
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 [when specified as temporomandibular joint aspiration] |
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 (ie, 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 |
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|
HCPCS |
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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 | Arthroplasty |
D7870 | Arthrocentesis |
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 |
D7899 | Unspecified TMD therapy, by report |
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|
ICD-10 Procedure |
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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] |
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ICD-10 Diagnosis |
|
G44.89 | Other headache syndrome |
M19.09 | Primary osteoarthritis, other specified site |
M19.91 | Primary osteoarthritis, unspecified site |
M26.50-M26.59 | Dentofacial functional abnormalities |
M26.601-M26.69 | Temporomandibular joint disorders |
M79.10-M79.12 | Myalgia, unspecified; mastication muscle; auxiliary muscles, head and neck |
S03.00XA-S03.03XS | Dislocation of jaw |
When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.
When services are also Not Medically Necessary:
For the diagnosis codes listed above for TMD and related diagnoses, for the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.
HCPCS |
|
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 |
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 prevalence of TMJD is in the range of 5 to 12% (NIDCR, 2018). The incidence is higher in younger individuals and in women. Although some cases can be linked to physical trauma or disease conditions, in most cases the cause is unknown.
The most frequent presenting symptom associated with TMD is pain, usually localized to the muscles of mastication, the preauricular area, and/or the TMJ. This pain may be related to trauma, (such as a blow to the face), inflammatory or degenerative arthritis, or may be due to 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.
Most cases of TMD can be treated without surgery. Treatments may include behavioral changes, physical therapy, pharmacologic therapy (e.g., oral medications for pain, anti-inflammatory injections), and reversible, removable, intraoral dental splints (also called occlusal orthotics or occlusal splints). Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. Such procedures include but are not limited to the following:
There are no criteria to identify people who would most likely benefit from surgery. 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 clinical outcome measurements (Al-Moraissi, 2017; Bouchard, 2017; Nandhini, 2018; Schiffman, 2007; Tatli, 2017; Truelove, 2006; Zhang, 2020).
In 2014, Schiffman and colleagues found that, although the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been reliable, they were below the target sensitivity of greater than or equal to 0.70 and specificity of greater than or equal to 0.95. This empirical finding prompted a revision. The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I include both a valid screening protocol for detecting any pain-related TMD, as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity greater than or equal to 0.86, specificity greater than or equal to 0.98). The authors stated:
TMD is the second most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability… Taken together, a new dual-axis Diagnostic Criteria for TMD (DC/TMD) will provide evidence-based criteria for the clinician to use when assessing patients, and will facilitate communication regarding consultations, referrals, and prognosis.
In 2017, the American Academy of Oral and Maxillofacial Surgeons (AAOMS) issued Parameters of Care (6th edition) which stated 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.
The National Institute of Dental and Craniofacial Research (2023) states the following on temporomandibular joint and muscle disorders:
Open surgery gives access to the temporomandibular joint through a cut (incision) next to the ear. It’s important to know that surgery makes permanent changes to your joint. There are no long-term research studies on the safety of open surgery for TMDs or on how well it works to relieve symptoms.
Surgery should only be considered if:
Several devices have obtained pre-market approval or clearance from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD. The FDA-approved labeling for these devices has similar indications. However, the published evidence evaluating clinical outcomes of these devices is limited and clinical utility has not been empirically established.
Definitions |
Analgesics: Medications that provide pain relief.
Arthroplasty: Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.
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.
Modified condylotomy: An extra-articular surgical procedure used to manage TMJ dysfunction. The primary purpose of the procedure is to increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence.
Occlusal orthotic device: A dental term used to describe a reversible, removable intraoral appliance, such as a splint.
Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.
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:
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
MIRO Therapy
Patient-Fitted TMJ Reconstruction Prosthesis
Temporomandibular Joint
TMJ
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis
TMJ Fossa-Eminence Prosthesis System
TMJ Fossa-Eminence Prosthesis System™
TMJ Patient Specific Fossa-Eminence Prosthesis System™
Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation).
TMJ Partial Temporomandibular Joint Replacement 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.
History |
Status | Date | Action | |||
Revised | 11/09/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised formatting of MN statement. Revised surgical procedures criteria. Added MIRO Therapy to NMN statement. Updated Discussion, References, and Index sections. | |||
Revised | 11/10/2022 | MPTAC review. Moved content related to iontophoresis to CG-MED-28. Removed content from MN and NMN statements that are addressed in other documents. Updated formatting in Clinical Indications section. Updated Description, Discussion, References and Index sections. Updated Coding section, removed 97033, D9130, D9920 no longer addressed. | |||
Reviewed | 2/17/2022 | MPTAC review. Updated References sections. | |||
Revised | 02/11/2021 | MPTAC review. Added “or’s” to list of surgical procedures in medically necessary statement. Edited criterion B in medically necessary statement on surgical procedures for clarification. Modified ‘not medically necessary’ statement on surgical procedures to include “when the above criteria are not met”. Discussion/General Information and References sections updated. Reformatted Coding section. | |||
| 10/01/2020 | Updated Coding section with 10/01/2020 ICD-10-CM changes; added M19.09. | |||
Revised | 02/20/2020 | MPTAC review. Pharmacologic therapy and therapeutic injections removed from medically necessary statement on nonsurgical treatments. Intra-articular injections of hyaluronic acid removed from not medically necessary statement. Discussion/General Information and References sections updated. | |||
| 10/01/2019 | Updated Coding section to correct ICD-10-CM diagnosis codes S03.00XA-S03.03XS. | |||
Revised | 03/21/2019 | MPTAC review. Clarified MN and NMN criteria and removed requirement for FDA approval. Description, Discussion/General Information, and References sections updated. Updated Coding section; removed D9940 deleted 12/31/2018; added 97033, D9130, D9920. | |||
| 09/20/2018 | Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added M79.10-M79.12 replacing M79.1. | |||
Reviewed | 03/22/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Discussion/General Information and References sections updated. | |||
Revised | 05/04/2017 | MPTAC review. Modified condylotomy was added to the surgical procedures for TMD considered medically necessary when criteria are met. References and Coding sections were updated. | |||
Reviewed | 11/03/2016 | MPTAC review. Updated the formatting of the Clinical Indications section. The Discussion section and References were updated. | |||
| 10/01/2016 | Updated coding section with 10/01/2016 ICD-10-CM changes. | |||
Reviewed | 11/05/2015 | MPTAC review. References were updated. Removed ICD-9 codes from Coding section. | |||
| 07/01/2015 | Updated Coding section with 07/01/2015 HCPCS changes; removed S8262 deleted 06/30/2015. | |||
Reviewed | 11/13/2014 | MPTAC review. Discussion and References sections were updated. Updated Coding section with 01/01/2015 CPT changes. | |||
Reviewed | 11/14/2013 | MPTAC review. Discussion section and References were updated. | |||
Reviewed | 11/08/2012 | MPTAC review. References were updated. | |||
Reviewed | 11/17/2011 | MPTAC review. 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. | |||
Pre-Merger Organizations | Last Review Date | Document Number | Title
| ||
Anthem, Inc. | N/A | N/A | N/A | ||
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, Inc. | 09/23/2004 | Clinical Guideline | Temporomandibular Joint Arthroplasty |
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