Coding Code Description CPT
20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
21010 Arthrotomy, temporomandibular joint
21050 Condylectomy, temporomandibular joint
21060 Menisectomy, partial/complete, temporomandibular joint (separate procedure)
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
21085 Impression and custom preparation; oral surgical splint
21089 Unlisted maxillofacial prosthetic procedure
21116 Injection procedure for temporomandibular joint arthrography
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
21480 Closed treatment of temporomandibular dislocation; initial or subsequent
21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent
21490 Open treatment of temporomandibular dislocation
29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
29804 Arthroscopy, temporomandibular joint, surgical
70328 Radiologic exam, temporomandibular joint, open and closed mouth; unilateral
70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral
70332 Temporomandibular joint arthrography, radiological supervision and interpretation
70350 Cephalogram, orthodontic
70355 Orthopantogram (eg, panoramic x-ray)
HCPCS
J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose
J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
S3900 Surface electromyography (EMG) CDT
D7880 Occlusal orthotic device
D7881 Occlusal orthotic device adjustment
D7899 Unspecified TMD therapy, by report
D7999 Unspecified oral surgery procedure
D9940 Occlusal guard
Introduction
The temporomandibular joint (TMJ) is the joint where the jawbone connects to the skull. There is one joint on each side of the jaw. The areas of the bones forming the joint are covered with cartilage and separated by a small disk. This disk helps keep joint movement smooth. Sometimes the disc erodes or moves out of its proper position. Arthritis may develop in the joint and damage the cartilage, or an injury can damage the joint. Regardless of the cause, TMJ disorders (TMJD) can result in pain and affect the function of the joint and the muscles that control jaw movement. TMJDs may go away without treatment, or pain relievers can be used to alleviate symptoms. This policy describes the services that the health plan covers (considers medically necessary) to diagnose and treat TMJ symptoms and disorders. On some plans, services to treat TMJ problems are limited to a specific benefit which may have a dollar limit.
Policy Coverage Criteria
Treatment Medical Necessity
Diagnostic procedures The following diagnostic procedures may be considered medically necessary in the diagnosis of temporomandibular joint (TMJ) disorder:
* Diagnostic x-ray, tomograms, and arthrograms
* Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations)
* Cephalograms (x-rays of jaws and skull)
* Pantograms (x-rays of maxilla and mandible)
Note: Cephalograms and pantograms should be reviewed on an individual basis.
Surgical treatments The following surgical treatments may be considered medically necessary in the treatment of TMJ disorder:
* Arthrocentesis
* Manipulation for reduction of fracture or dislocation of the TMJ
* Arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment
* Open surgical procedures (when TMJ disorder results from congenital anomalies, trauma, or disease in patients who have failed conservative treatment) including, but not limited to:
o Arthroplasties
o Condylectomies
o Meniscus or disc plication
o Disc removal
Nonsurgical treatments The following nonsurgical treatments may be considered medically necessary in the treatment of TMJ disorder:
* Intraoral removable prosthetic devices/appliances (encompassing fabrication, insertion, adjustment)
* Pharmacologic treatment (eg, anti-inflammatory, muscle relaxing, analgesic medications)
Diagnostic procedures The following diagnostic procedures are considered investigational in the diagnosis of TMJ disorder:
* Arthroscopy of the TMJ for purely diagnostic purposes
* 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 TMJD)
* Electromyography (EMG), including surface EMG
* Joint vibration analysis
* Kinesiography
* Muscle testing
* Neuromuscular junction testing
* Range-of-motion measurements
* Somatosensory testing
* Standard dental radiographic procedures
* Thermography
* Transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJD)
* Ultrasound imaging/sonogram
Nonsurgical treatments The following nonsurgical treatments are considered investigational in the treatment of TMJ disorder:
* Biofeedback
* Botulinum toxin
* Dental restorations/prostheses
* Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function
* Electrogalvanic stimulation
* Hyaluronic acid
* Iontophoresis
* Orthodontic services
* Percutaneous electrical nerve stimulation (PENS)
* Transcutaneous electrical nerve stimulation (TENS)
* Ultrasound
.
Description
Temporomandibular joint disorder (TMJD) refers to a group of disorders characterized by pain in the temporomandibular joint and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of nonsurgical and surgical treatment possibilities for patients whose symptoms persist.
Background
Temporomandibular joint disorder (TMJD; also known as temporomandibular joint syndrome) refers to a cluster of problems associated with the temporomandibular joint (TMJ) and musculoskeletal structures. The etiology of TMJD remains unclear and is believed to be multifactorial. TMJD are often divided into two main categories: articular disorders (eg, ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, joint dislocation) and masticatory muscle disorders (eg, myofascial pain, myofibrotic contracture, myospasm, neoplasia). Diagnosis
In the clinical setting, TMJD is often a diagnosis of exclusion and involves physical examination, patient interview, and review of dental records. Diagnostic testing and radiologic imaging is generally only recommended for patients with severe and chronic symptoms. Diagnostic criteria for TMJD have been developed and validated for use in both clinical and research settings.1-3 Symptoms attributed to TMJD are varied and include, but are not limited to, clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).
Treatment
For many patients, symptoms of TMJD are short-term and self-limiting. Conservative treatments, such as eating soft foods, rest, heat, ice, and avoiding extreme jaw movements, and antiinflammatory medication, are recommended before consideration of more invasive and/or permanent therapies, such as surgery.
The most recent literature review was through December 20, 2016. Recent literature searches have concentrated on identifying systematic reviews and meta-analyses. For treatment of temporomandibular joint disorders (TMJD), the focus has been on studies that compared novel treatments with conservative interventions and/or placebo controls (rather than no-treatment control groups) and that reported pain reduction and/or functional outcomes (eg, jaw movement).
Botulinum Toxin A 2015 systematic review by Chen et al evaluated the literature on botulinum toxin (Botox) for treatment of temporomandibular joint disorders.36 Eligibility included RCTs comparing any dose or type of botulinum toxin with any alternative intervention or placebo. Five RCTs met the inclusion criteria; three were parallel group studies, and two were crossover studies. Study sizes tended to be small; all but 1 study included 30 or less participants. Three of the 5 studies were judged to be at high risk of bias. All studies administered a single injection of botulinum toxin and followed patients up at least 1 month later. Four studies used a placebo (normal saline) control group and the fifth used botulinum toxin to fascial manipulation.
The primary outcome was a validated pain scale. Data were not pooled due to heterogeneity among trials. In a qualitative review of the studies, only 2 of the 5 trials found a significant short-term (1-to-2 months) benefit of botulinum toxin compared with control on pain reduction. Summary of Evidence
For individuals who have suspected temporomandibular joint disorder (TMJD) who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test accuracy, test validity, and other performance measures. None of the systematic reviews found that these diagnostic techniques accurately identify patients with TMJD and many of the included studies had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes randomized controlled trials (RCTs) and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Other systematic reviews found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs placebo]). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electrical nerve stimulation, orthodontic services, or hyaluronic acid, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic reviews did not find that these technologies reduced pain or improved functional outcomes significantly more than control treatments. Moreover, many individual studies were small and/or had methodologic limitations. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have a confirmed diagnosis of TMJD, who receive arthrocentesis or arthroscopy, the evidence includes RCTs and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Only 1 review, which included 3 RCTs, compared arthrocentesis or arthroscopy with nonsurgical interventions for TMJD. Pooled analyses of the RCTs found that arthrocentesis and arthroscopy resulted in superior pain reduction than control interventions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. A systematic review of RCTs found insufficient evidence that botulinum toxin improves the net health outcome in patients with temporomandibular joint disorders. Studies tended to be small, have a high risk of bias, and only 2 of 5 RCTs found that botulinum toxin reduced pain more than a comparator.