Temporomandibular Joint Dysfunction

Tomography

May be considered clinically appropriate, if the clinical symptoms of TMD are present and non-surgical conservative treatment for bruxism and malocclusion have failed. Indications for tomography include:

• pain specific to the joint,
• crepitus,
• evidence of severe condylar displacement, *limitation of motion and persistent pain after treatment.

Arthrogram

May be considered clinically appropriate for TMD diagnosis. Indications for an arthrogram includes:

• suspected adhesions of the meniscus,
• suspected perforations of the meniscus,
• presence of joint crepitus,
• pain and failure of conservative therapy,
• meniscus not visible on Computed tomography (CT) or Magnetic resonance imaging (MRI),
• when CT and MRI do not correlate with the symptoms and dynamic study of the meniscus is needed.

Magnetic Resonance Imaging (MRI)

• Non-covered service.
• Procedure is considered medical.
• Submit on medical claim form with applicable medical Current Procedural Terminology (CPT®) code and diagnosis code.

Full mouth series/Panoramic x-ray

No additional benefits will be available.

Physical Therapy (PT)

• Non-covered service.
• Procedure is considered medical.
• Submit on medical claim form with applicable medical Current Procedural Terminology (CPT®) code and diagnosis code.

Electromyograph (EMG)

• Non-covered service.
• Considered investigational.

Acupuncture

• Non-covered service.
• Procedure is considered medical.
• Submit on medical claim form with applicable medical Current Procedural Terminology (CPT®) code and diagnosis code.

Continuous passive motion

Non-covered service.

Arthroscopy, diagnostic

Subject to review, documentation required. If there is another arthroscopic procedure, it is considered incidental. If diagnostic arthroscopy precedes an open arthrotomy, it is considered a secondary procedure. Indications for arthroscopy surgery include:

• Anterior disc displacement – without reduction, with pain.
• Anterior disc displacement – with reduction, with pain, with deformed disc.
• Anterior disc displacement – with reduction, with pain, young patient with mandibular dysfunction.
• Fibrous adhesions in the upper or lower joint compartment.
• Normal mandibular function, but with disc perforation, with or without osteoarthritic changes.
• Foreign body visible on x-rays.

Arthroscopy, surgical assistant

Non-covered service.

Arthroscopic repair or reconstruction of the meniscus/disc

Medical necessity must be established. Referral should be accompanied by the operative report.

Arthroplasty

Indications for arthroplasty include:

• Displaced or torn meniscus.
• Presence of spurs, necrosis of the condyle; or arthritic deterioration.
• Failure of conservative therapy over at least 6 months; positive arthrogram or MRI.
• Failure of medical treatment and evidence of severe joint disease.
• Ankylosis present.
• All documentation needed for review should include reports from all results of testing performed, conservative treatment, history and physical and operative reports from previous procedures performed on the TMJ.

Coronoidectomy

• Non-covered dental service.
• Procedure is considered medical.
• Submit on medical claim form with applicable medical CPT® code and diagnosis code.

Microvascular second metatarsophalangeal total joint transplant

This procedure is considered experimental and investigational; therefore, a non-covered service.

Diagnostic splint/acute pain reduction in TMD

• Non-covered dental service.
• Procedure is considered medical.
• Submit on medical claim form with applicable medical Current Procedural Terminology (CPT®) code and diagnosis code.

Repositioning splint

The purpose of the splint is to establish a functional relaxed muscle/jaw relationship for stabilization. If no relief in six months, the patient is to be re-evaluated. Review includes:

• Medical necessity.
• Any future replacement splints will be reviewed on an individual consideration if outside the six months global period of a previous splint.
• Mandibular repositioning sleep device, snore guard, etc., for sleep apnea: refer to medical policy for sleep apnea.

Dental services which are not eligible for medical benefits under TMD guidelines are:

• Occlusal equilibration
• Full mouth reconstruction
• Dentures
• Orthodontia
• Appliance or restoration to increase vertical dimension or restore occlusion

D0320

Temporomandibular Joint Arthrogram, Including Injection

D0322

Tomographic Survey

D7820

Closed Reduction of Dislocation

D7840

Condylectomy

D7852

Disc Repair

D7856

Myotomy

D7860

Arthrotomy

D7870

Arthrocentesis

D7872

Arthroscopy - Diagnosis, With or Without Biopsy

D7874

Arthroscopy - Surgical: Disc Repositioning and Stabilization

D7876

Arthroscopy - Surgical: Discectomy

D7880

Occlusal Orthotic Device, By Report

D7991

Coronoidectomy