There are three basic approaches to the treatment of temporomandibular joint (TMJ) syndrome (524.60-524.69):

1. Medical-Surgical: Medical visits, arthrocentesis, and injections of the joint are eligible for payment when reported with a diagnosis of TMJ dysfunction.

   Claims reporting injections of tendon sheaths, ligaments, and trigger points should be processed in accordance with Medical Policy Bulletin S-7. Coverage for injections of muscles is determined according to individual or group customer benefits.

   Physical medicine (including modalities such as heat/cold treatment, manipulation, and electrogalvanic electrical stimulation) is covered when provided as treatment for TMJ syndrome.

   Transcutaneous electrical nerve stimulation (TENS) is also eligible for reimbursement when provided in the assessment of TMJ dysfunction. (Refer to Medical Policy Bulletin Z-7 for additional guidelines of TENS).

   Vapo-coolant spray (ethyl chloride) is a surface (local) anesthetic and should be denied. A participating, preferred, or network provider can bill the member for the denied service.

   Manipulation for the reduction of a fracture or dislocation of the temporomandibular joint (e.g., 21480-21490), or manipulation of the joint under anesthesia, are considered surgical procedures and should be paid as such. However, these codes are inappropriate for treatment of TMJ dysfunction without dislocation and will be denied as not medically necessary. Codes 21480, 21490 are to be used only for a dislocated condyle beyond the eminentia to the fossa.

   Arthroscopic procedures of the temporomandibular joint are eligible for payment. Diagnostic arthroscopy is to be coded as 29800. Therapeutic arthroscopy is to be coded as 29804.

   NOTE:

   Major surgical intervention is rarely required in the treatment of TMJ dysfunction. Any claim for a major surgical procedure such as a meniscectomy, arthroplasty, or total condylectomy should be referred for medical review.

   
   

   
   

   Diagnostic x-rays taken in conjunction with the treatment of TMJ dysfunction are eligible for reimbursement. Claims reporting such x-rays should be processed under the appropriate diagnostic radiology code (the 70000 series). Specifically excluded from coverage are the dental radiography codes (D0210-D0350).

   Cephalograms (70350) and pantograms (70355) will be reviewed for medical necessity on an individual consideration basis.

   The following services are ineligible for payment on the basis that they are not of proven value in the diagnosis of this condition:

   Electromyography (EMG) (95867, 95868)
   Iontophoresis (97033)
   Lateral skull x-rays (70250-70260)
   Neuromuscular junction testing (95937)
   Somatosensory testing (95925)
   Nuclear medicine studies (78300, 78305)
   Transcranial x-rays (70250-70260)
   Ultrasound (76536)

   
   

   NOTE:

   Services denied on the basis of being of unproven value for this condition are considered medical necessity denials. A participating, preferred, or network provider cannot bill the member for the denied service.

   
   

2. Psychiatric/Psychological: TMJ dysfunction is often a psychosomatic condition, usually resulting from tension or stress. Bruxism is a common tension habit which can lead to the TMJ syndrome. Payment should be made for psychiatric/psychological visits if reported as such with a diagnosis of TMJ dysfunction.

3. Mechanical: Temporary orthotics, provided that splints or appliances may be limited to one every three years, and that all adjustments to the appliance performed during the first six months of its installation, are considered part of the total appliance fee.  Thos appliances designed for orthodontic purposes such as bionators, functional regulators, Frankel devices and similar devices are not covered.  Any method to alter occlusion of the teeth is considered a mechanical approach.  Frequently, an intraoral appliance (D7880, S8262) will be prescribed.  The intraoral appliance will be covered under the member's medical-surgical benefit.   

Also, continuous passive motion (CPM) devices (E0935) used in the treatment of TMJ, e.g., Therapacer (an electronic device), are considered experimental/investigational, and are not eligible for reimbursement. A participating, preferred, or network provider can bill the member for the denied service. Based on scientific evidence, the use of CPM devices for this application has not been proven effective nor does its use impact or improve health outcomes.

However, the jaw motion rehabilitation system, Therabite, a manual, hand-held, single patient use device is eligible for reimbursement. Procedure codes E1700-E1702 should be used to report this device.

See Medical Policy Bulletin E-1 for information on the eligibility of jaw motion rehabilitation systems and CPM devices for other conditions.

The following guidelines are applicable when these services are reported for the treatment of TMJ dysfunction:

• Arthrogram (70332) indicated for presurgical evaluation. Should not be performed in addition to an MRI scan.
• CT scan (70486-70488) - indicated for hard tissue presurgical evaluation.
• Injection of anesthetic agent, trigeminal nerve (64400) - allow only once per course of treatment.
• Muscle testing (95831) - refer to Medical Policy Bulletin V-31 for information.
• MRI scan (70336) - indicated for soft tissue presurgical evaluation.
• Physical medicine, in general, should not exceed four weeks in duration.
  

  NOTE:

  Additional physical medicine services are eligible only with documentation for individual consideration.

• Range of motion measurements (95851) - refer to Medical Policy Bulletin V-31 for information.
• The following services are ineligible for payment on the basis that they are not of proven value in the diagnosis of this condition:

Kinesiography (97799)
Ultrasonic doppler auscultation

NOTE:

Services denied on the basis of being of unproven value for this condition are considered medical necessity denials.

See Medical Policy Bulletin Y-1 guidelines regarding physical medicine coverage.

Under the Steel contracts, TMJ dysfunction is considered a dental condition. As such, this policy is not applicable. However, if the diagnosis is osteoarthritis, degenerative arthritis, traumatic arthritis, ankylosis, or other organic pathology of the temporomandibular joint, the condition is considered medical. In such cases, the above policy is applicable for specific services as identified in the benefits schedule.

Description

The temporomandibular joint connects the mandible (lower jaw) and the temporal bone (located in front of the ears). Dysfunction of this joint can involve hard or soft tissues and may be caused by either organic disease or functional joint abnormalities. Symptoms are varied and include, but are not limited to, clicking sounds in the jaw, headaches, trismus, and pain in the ears, neck, arms, and spine. TMJ dysfunction can also be referred to as any of the following: cranial-cervical syndrome, myofascial pain-dysfunction syndrome, asymmetrical motor neuropathy, cervicalgia, localized myospasm, cephalgia, musculoskeletal dysfunction, neural entrapment, vascular instability, myalgia/myositis.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Benefits are available for intraoral appliances (D7880, E1700, E1701, E1702, S8262) and devices such as splints. Visits to fabricate, insert, and adjust the appliance are also covered.

In addition, occlusiography or mandibular kinesiography are covered if required to diagnose the source of pain or to monitor covered treatment.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition. TMJ services for conditions other than those documented are considered eligible when determined medically necessary based on the patient's condition.

See Medical Policy Bulletin Y-1 for program variations regarding physical medicine coverage.

PRN References

10/2001, Guidelines clarified for specific durable medical equipment

West Virginia Regulations  §114-29-5.1E