OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy 0028

Temporomandibular Disorders (TMD/TMJ) — Clinical Policy Bulletin

Customize your policy alerts

Sign up for Aetna Policy 0028 alerts

Get alerted when Policy 0028 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines coverage, medical necessity criteria, diagnostic testing, non-surgical and surgical management, and investigational exclusions for temporomandibular disorders and TMJ dysfunction when benefits cover TMD/TMJ care.

Policy Summary

PayerAetna

PolicyTemporomandibular Disorders (TMD/TMJ) — Clinical Policy Bulletin

Policy CodePolicy 0028

Change TypeNo material change

Effective DateAug 1, 1995

Last ReviewMar 17, 2023

Next Review DateJan 11, 2024

Key ActionSubmit problem-specific history, exam, imaging, 3–6 months of documented non-surgical management, and proposed treatment plan for TMJ surgical precertification review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3+ monthsmin non-surgical management before surgery

6 monthsmax usual appliance duration before review

1oral splint limit

20+codes listed

155references

Coverage and Medical Necessity Criteria

inv-01: General medical necessity criteria for TMJ surgery

Covered when ALL of the following are met:

General surgical necessity: 1) Severe pain or functional disability is produced by an intra-capsular condition; AND 2) The intracapsular condition is confirmed by MRI, CT, or other imaging; AND 3) The condition has not responded to nonsurgical management and surgery is the only remaining option. Nonsurgical management should include three or more months of appropriate therapies (professional physical therapy, pharmacologic therapy, behavioral therapy such as CBT or relaxation therapy, manipulation when appropriate, and reversible intra-oral appliances).>= 3 months where appropriate

Immediate surgery may be considered without prior nonsurgical management in specific circumstances (e.g., bony ankylosis, failed TMJ total joint prosthetic implants).

inv-02: Procedure-specific surgical criteria (examples)

Each procedure covered only when procedure-specific findings are present and general criteria met:

Arthrocentesis with insufflation, lysis, and lavage is medically necessary when imaging and clinical examination reveal anchored disc phenomenon, anterior disc displacement without reduction and without effusion, osteoarthritis without fibrosis or loose bone particles, open lock, or hemarthrosis.

Policy Summary

PayerAetna

PolicyTemporomandibular Disorders (TMD/TMJ) — Clinical Policy Bulletin

Policy CodePolicy 0028

Change TypeNo material change

Effective DateAug 1, 1995

Last ReviewMar 17, 2023

Next Review DateJan 11, 2024

Key ActionSubmit problem-specific history, exam, imaging, 3–6 months of documented non-surgical management, and proposed treatment plan for TMJ surgical precertification review.

SourceLink

On This Page

Arthrocentesis defined as insertion of two separate single-needle portals or a single double-needle portal for input and output of fluids, with lavage, mandibular manipulation for lysis of adhesions, and possible elective steroid infusion.

Therapeutic arthroscopy is medically necessary when MRI or other imaging confirms adhesions, fibrosis, degenerative joint disease, or internal derangement of the disc that requires internal modification.

Open procedures (disc repair/removal/arthroplasty): Open surgical procedures including meniscus or disc repositioning/plication, disc repair, disc removal with or without replacement, arthroplasty or arthrotomy (e.g., condylectomy, eminectomy/eminoplasty) are medically necessary when MRI or other imaging documents osteoarthritis/osteoarthrosis, severe disc displacement with degenerative changes or perforation, or severe scarring often resulting from prior injury or procedure, and the patient has failed nonsurgical management.

inv-03: Joint replacement and autogenous graft criteria

Covered when used as salvage and when general criteria met and imaging documents at least one of the following:

Joint replacement indications: 1) Temporal bone no longer provides a smooth articular fossa; OR 2) Damaged condyles not ball-shaped; OR 3) Persistent, stable inflammatory arthritis unresponsive to other modalities; OR 4) Recurrent fibrous or bony ankylosis unresponsive to other modalities; OR 5) Loss of mandibular condylar height and/or occlusal relationship due to trauma, resorption, pathology or congenital anomaly; OR 6) Failed autologous bone graft or alloplastic reconstruction.

Joint replacement limited to FDA-approved prostheses and used as salvage after unsuccessful conservative and other surgical treatments; document imaging findings and prior treatments.

Autogenous grafts (e.g., costochondral, cartilage, dermal, fat, fascial) may be medically necessary upon individual case review. Costochondral grafts are considered medically necessary when general joint replacement criteria are met, for congenital absence/deformity, or reconstruction post head and neck tumor resection.

Individual case review required; document indication and prior interventions.

inv-04: Medically necessary non-surgical therapies

Covered when clinically indicated:

Reversible intra-oral appliances (occlusal splints) may be medically necessary in selected cases with clinically significant masticatory impairment with documented pain and/or loss of function. Only one appliance is considered medically necessary; prolonged use (>6 months) requires individual case review. Appliances for bruxism are typically excluded under medical plans; check benefit descriptions.prolonged use > 6 months requires individual review

Adjustments within 6 months are medically necessary; replacements/repairs reviewed as appropriate.

Physical therapy (therapeutic exercises, thermal modalities, manipulation, spray-and-stretch, electro-galvanic stimulation) is a medically necessary conservative treatment for TMD/TMJ.

See related policy CPB 0325 for additional criteria.

Pharmacologic and behavioral therapies: Non-opiate analgesics and NSAIDs for mild-to-moderate pain, low-dose tricyclic antidepressants for chronic pain and nocturnal bruxism, adjuvant agents for unremitting pain, and relaxation/CBT/biofeedback are medically necessary when indicated. Opiates, corticosteroids, anxiolytics and muscle relaxants may be medically necessary for refractory pain.

inv-05: Coverage criteria for imaging and surgical management

Covered when clinical and procedural indications met; non-surgical therapy generally required prior to invasive interventions

Conservative therapy prior to surgery: Non-surgical conservative and reversible therapies (occlusal appliance, physical therapy, medical management, relaxation/CBT, biofeedback) should be tried and documented prior to surgical intervention.trial period often 2-3 months for appliances; generally >= 3 months of conservative care prior to surgery

NIH and specialty society guidance emphasize a conservative-first approach; document nature and results of therapies.

Advanced imaging for surgery: Specialized radiologic studies (CT, MRI, TMJ-specific radiographs) are considered medically necessary only when surgery is being considered or anticipated; documentation must support anticipated surgical management.documentation must support anticipated surgical management

Evidence for diagnostic efficacy of MRI is limited but MRI is useful for assessing internal derangements when surgery is planned.

Surgical candidacy: Surgery indicated only when nonsurgical therapy is ineffective and pain and/or dysfunction are moderate to severe; not indicated for asymptomatic or minimally symptomatic patients or for prevention.failure of conservative therapy

AAOMS Parameters of Care (2012) referenced; irreversible procedures lack support without clear indications.

inv-06: Evidence-informed coverage considerations

Evidence summary and clinical implications relevant to coverage decisions:

Total joint prosthesis evidence: FDA-approved total joint prostheses have case-series and comparative data showing improvements in pain, function, and maximal incisal opening, but follow-up completeness is limited and device-related events have been reported; comparative studies suggest device-specific outcome differences.

Requires careful patient selection, documentation of prior failed therapies, and device-specific outcome monitoring.

Contraindications and caution: Total joint devices are not intended for partial reconstruction or for use in patients with active/chronic infection, insufficient bone to support the device, immature skeleton, or hyper-functional habits (e.g., clenching/grinding); additional surgeries after implants should be approached with caution.

Document contraindicating factors and rationale for implant use.

Conservative therapies evidence: Manual therapies and other conservative modalities show variable, low-to-moderate quality evidence with some mid-term benefits for pain and mouth opening; phototherapy and other adjuncts have heterogeneous results and limited high-quality evidence.

Conservative, multidisciplinary approaches are preferred before irreversible interventions.

Investigational therapies: Stem cell and other novel tissue-engineering approaches remain investigational; evidence insufficient to support routine use outside research or individualized review.

Consider investigational status in coverage decisions.

inv-07: Evidence summaries — investigational/adjunctive therapies

Evidence summaries and conclusions from cited studies and systematic reviews (no explicit coverage criteria provided in this excerpt).

Adjunctive/investigational therapies summary: Multiple investigational or adjunctive therapies (PRP/PRGF, HA, botulinum toxin, stem cell therapy, tDCS, intra-articular biologics, phototherapy, cryo-analgesia, propranolol, AI diagnostics) have been evaluated; systematic reviews and RCTs report mixed, heterogeneous, and generally low-to-moderate quality evidence with limited consensus supporting routine use.

Standardized protocols and higher-quality trials are generally lacking; consider individualized review and documentation when used.

inv-08: Evidence‑based coverage considerations

Coverage considerations based on the evidence summarized below:

Arthrocentesis vs adjuncts: Arthrocentesis alone effectively reduces pain and improves jaw function in TMJ osteoarthritis; addition of HA or corticosteroid at the end of arthrocentesis did not consistently improve final outcomes in some reviews.

Consider simple arthrocentesis before adjunctive intra-articular supplements.

PRP/PRGF intra-articular injections show slight or inconsistent clinical benefits versus controls in systematic reviews and small RCTs; lack of standardized preparation protocols limits conclusions.

Prior authorization and detailed documentation recommended when considered.

Hyaluronic acid (HA): HA injections reduced pain versus saline/placebo in some trials but evidence is inconclusive versus other modalities; heterogeneity in molecular weight, dosing and protocols limits firm conclusions.

Consider HA when prior corticosteroid or conservative therapy has failed and with documented indication.

Minimally invasive dislocation therapies: Minimally invasive options for recurrent TMJ dislocation (e.g., autologous blood injection) report ~80% success at 12 months in case series and reviews; evidence is largely non-randomized.

Document prior management, frequency of dislocation, and rationale for intervention.

Novel/adjunctive therapies: Other novel or adjunctive therapies (e.g., ozone, magnetic stimulation, cryo-analgesia, botulinum toxin, propranolol) have preliminary or mixed evidence; use should be individualized with informed consent and documentation of prior failed conservative therapies.

Many such therapies are considered investigational or of limited evidence for routine coverage.

inv-09: Intra-articular corticosteroid injections for TMJ (including JIA)

Covered when ALL of the following are met

Main criteria: 1) Clinical diagnosis of symptomatic TMJ arthritis with objective findings (e.g., pain, limited maximal incisal opening [MIO], MRI evidence of TMJ inflammation or effusion); 2) Prior trial of appropriate conservative therapy unless contraindicated (e.g., systemic DMARDs for JIA, NSAIDs, splinting, physical therapy) or clear clinical indication for local therapy; 3) Procedure performed with image guidance (US or CT) or documentation confirming accurate intra-articular needle placement; 4) Documentation of expected benefit and plan for follow-up (pain and MIO assessment).

Imaging confirmation of intra-articular placement (CT or ultrasound) recommended to support accuracy and reduce risk of denial; studies in JIA showed clinical improvement with image-guided corticosteroid injections.

inv-10: Hyaluronic acid (HA) vs corticosteroid intra-articular injection

Evidence summary / coverage consideration

Evidence note: Some randomized data report greater and more durable symptomatic and mouth-opening improvement with multi-dose HA (e.g., 3 weekly injections) compared to a single corticosteroid injection in certain studies; high molecular weight HA may increase mouth opening more. Consider HA when prior corticosteroid or conservative therapy has failed and documented indication exists.

Heterogeneity in protocols and mixed quality of evidence limit definitive coverage statements; document prior therapies and rationale.

inv-11: Dextrose prolotherapy for TMJ hypermobility

Evidence summary

Evidence note: Pooled data from three RCTs showed statistically significant reductions in mouth opening (MMO) and pain with dextrose prolotherapy versus placebo, but no clear evidence for reduction in subluxation/dislocation episodes; trials were small and heterogeneous.

Further high-quality RCTs with standardized protocols are needed.

inv-12: Minimally invasive techniques for recurrent TMJ dislocation

Coverage consideration

Evidence note: Minimally invasive techniques for recurrent TMJ dislocation (e.g., autologous blood injection with ~80% success at 12 months, OK-432 sclerotherapy, laser capsulorrhaphy, botulinum toxin) and surgical options (disc plication, eminoplasty, eminectomy) have been reported in case series and reviews; consider when conservative measures fail and document recurrent dislocation frequency and prior management.

Evidence largely from case series; individual case review and documentation recommended.

inv-13: Cryo-analgesia for refractory TMJ pain

Coverage consideration

Evidence note: Cryo-analgesia for refractory TMJ pain has limited evidence from small retrospective series showing short-term VAS improvement in patients who failed conservative treatments; long-term benefit is inconsistent and procedure is considered investigational without stronger evidence.

Consider only for refractory cases with documentation of failed therapies and informed consent about limited evidence.

inv-14: Propranolol for TMD myalgia

Evidence summary

Phase IIb trial outcomes: A randomized, double-blind, placebo-controlled phase IIb trial of extended-release propranolol (60 mg BID) in TMD myalgia showed no significant difference in mean facial pain index (FPI) reduction at 9 weeks versus placebo, but a greater proportion of propranolol-treated patients achieved >=30% and >=50% FPI reductions (NNT ~6); adverse effects included fatigue, dizziness, and sleep disorder.

Findings support further research; off-label use should be documented and monitored for adverse effects.

inv-15: Artificial intelligence diagnostics for TMD

Informational

Evidence note: AI diagnostic models for TMD report high pooled accuracy (pooled accuracy ~0.91) in retrospective studies, but certainty of evidence is very low and risk of bias is high; AI may augment diagnosis but is not a definitive diagnostic standard.

Use AI results cautiously and maintain conventional diagnostic workup; further high-quality research needed.

inv-16: Low-level laser / photo-biomodulation for myofascial TMD

Evidence summary

Evidence note: Systematic reviews and meta-analyses of low-level laser / photo-biomodulation for myofascial TMD show heterogeneous results: some trials report small short-term pain benefit and increased mouth opening, but most studies have low methodological quality and considerable variability in devices and protocols; overall clinical benefit for mastication is unclear.

Further high-quality, standardized RCTs are needed; if used, document device parameters and treatment protocols.

The policy lists numerous diagnostic procedures, non-surgical treatments, and surgical interventions that are considered experimental or investigational due to insufficient or inconsistent evidence. Examples explicitly identified include diagnostic technologies (e.g., artificial intelligence tools, kinesiography, joint vibration analysis, EMG), many adjunctive non‑surgical therapies (e.g., ozone therapy, cryo‑analgesia, photo‑biomodulation/GaAlAs laser, PRP/PRGF, intra‑articular hyaluronic acid in some contexts, botulinum toxin for certain TMD indications), and selected surgical techniques not meeting the stated procedure‑specific criteria. These items should be treated as investigational for coverage decisions unless supported by robust, plan‑specific clinical documentation or included within an approved clinical trial or specialty consult.

Intra‑oral appliances used for bruxism are typically excluded from coverage under Aetna medical plans; coverage depends on the member’s specific benefit plan and dental coverage. When an appliance is covered for TMD/TMJ therapy, Aetna considers only one appliance medically necessary and prolonged use beyond 6 months requires individual case review. Providers should check the member’s benefit description to determine whether dental plan coverage applies.

Specialized radiologic studies (for example, cephalometric x‑rays, tomograms, submental vertex radiographs) are not considered medically necessary for routine evaluation of TMD unless surgery is being considered. Advanced TMJ imaging (CPTs such as 70328, 70330, 70336 and CT/MRI codes 70486/70540–70543) and dental radiology HCPCS/D codes are covered only when documentation supports anticipated surgical management; absent that surgical indication, these studies may not be covered.

Certain total joint prostheses that have been removed from the market (for example, the Vitek‑Kent prosthesis and silastic implants) are explicitly described as not medically necessary because of poor biocompatibility, increased wear/fragmentation, and foreign‑body reactions. Use of these removed or discontinued devices is not supported for coverage.

The document describes many therapies as investigational or supported by limited, low‑quality evidence; although not all are listed as formal exclusions in this excerpt, examples include stem cell–based interventions, various intra‑articular biologics and novel devices, and some neuromodulation or adjunctive therapies. Because evidence is heterogeneous and often of low quality, these therapies generally require careful case‑level justification prior to coverage and may be denied when requested without robust supporting data.

Procedures or intra‑articular injections with unproven or inconsistent efficacy—such as routine use of standardized hyaluronic acid (HA) or platelet‑rich plasma (PRP/PRGF) protocols—are identified as having heterogeneous evidence. When efficacy is unproven or preparation/protocols are not standardized, these interventions may be considered investigational or excluded unless clinical documentation demonstrates prior failure of conservative therapies and a clear rationale for use.

Cryo‑analgesia and certain low‑level laser/photo‑biomodulation treatments (e.g., GaAlAs lasers) have limited supporting data and are not established as standard therapies for TMD. The policy notes small, preliminary case series or heterogeneous trial results for these modalities; absent stronger evidence, they are considered investigational and not routinely covered.

The policy includes an explicit list of items considered experimental or investigational and therefore not medically necessary for TMD/TMJ dysfunction. The list includes, but is not limited to, intra‑articular hyaluronic acid and platelet‑rich plasma injections (in some contexts), ozone therapy, cryo‑analgesia, laser capsulorrhaphy, many alternative/adjunctive devices (e.g., magnetic neurostimulators, MIRO therapy), and permanent mandibular repositioning procedures. These items require specific, high‑quality evidence and plan‑level justification before coverage will be considered.

Several specialized radiologic studies and particular HCPCS/dental device and supply codes are described as not medically necessary or not covered when selection criteria are not met. Advanced TMJ imaging codes (e.g., 70328–70336, 70486–70488, 70540–70543) and dental device codes (e.g., certain prosthodontics and TMD supply codes) are covered only when linked to anticipated surgical management; otherwise these codes may be denied or considered not covered under the benefit.

Irreversible mandibular repositioning procedures—including equilibration, orthodontic tooth movement solely to alter occlusion for TMD, full‑mouth reconstruction, and orthognathic surgery—are not supported as standard therapies for TMD. The policy cites biologic homeostasis arguments and evidence that most TMDs are best managed with conservative therapies, concluding that irreversible repositioning procedures are generally not medically necessary for treating TMD.

Stem cell–based approaches for TMJ repair and regeneration are described as promising experimentally, but their effectiveness for TMD has not been established. Similarly, intra‑articular ketamine showed no meaningful benefit in controlled testing. The policy therefore treats these interventions as investigational pending higher‑quality evidence.

Routine intra‑articular administration of hyaluronic acid or PRP/PRGF without prior documentation of failed conservative therapies or an evidence‑based rationale is considered unsupported by the available literature. Systematic reviews report heterogeneous protocols and inconsistent benefits; as a result, routine use may be considered investigational or not medically necessary unless detailed documentation justifies the intervention.

Systematic reviews of GaAlAs low‑level laser therapy report small, inconsistent short‑term pain benefits and no clear improvement in maximal mouth opening (MMO). The evidence base is heterogeneous and of limited quality, and the policy concludes there is insufficient evidence to recommend GaAlAs laser therapy for durable functional improvement.

Procedural, Device, and Diagnosis Codes

Covered CPT / HCPCS codes (selected examples)CPTCovered

20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles.
20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance.
20910	Cartilage graft; costochondral (autologous).
21010	Arthrotomy, temporomandibular joint.
21050	Condylectomy, temporomandibular joint (separate procedure).
21060	Meniscectomy, partial or complete, temporomandibular joint (separate procedure).
21070	Coronoidectomy (separate procedure).
21073	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service.
21085	Oral surgical splint.

1–10 of 20

1/2

Procedures considered experimental/investigational (examples)CPTExperimental

0232T	Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed.
0481T	Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed.

Additional imaging and related codes referencedCPT

70300	Radiologic examination, teeth; single view.
70487	Computerized tomography, maxillofacial area; with contrast material(s).
70488	Computerized tomography, maxillofacial area; without contrast material, followed by contrast material and further sections.

Advanced TMJ imaging and dental HCPCS referencedmixed

70328	Radiologic examination, temporomandibular joint, open and closed mouth; unilateral (covered only when used in conjunction with anticipated surgical management).
70330	Radiologic examination, temporomandibular joint, bilateral (covered only when used in conjunction with anticipated surgical management).
70336	Magnetic resonance imaging, temporomandibular joint(s) (covered only when used in conjunction with anticipated surgical management).

Procedural CPTs (selected)CPT

20560	Needle insertion(s) without injection(s); 1 or 2 muscle(s).
20561	Needle insertion(s) without injection(s); 3 or more muscles.
21120-21123	Genioplasty (range).
21125-21127	Augmentation mandibular body or angle (range).
21141-21147	Reconstruction midface, Lefort I (range).
21194-21199	Reconstruction/osteotomy of mandibular rami/body including genioglossus advancement and grafting (range).
21206-21209	Osteotomy, maxilla, segmental; osteoplasty facial bones (range).
21465	Open treatment of mandibular condylar fracture.
21480	Closed treatment of temporomandibular dislocation; initial or subsequent.
21247	Reconstruction of mandibular condyle with bone and cartilage autografts.

1–10 of 11

1/2

Diagnostic/therapeutic CPTsCPT

38205-38242	Hematopoietic progenitor cell and bone marrow harvesting/transplantation codes range.
70300-70320	Radiologic examination, teeth (single to full mouth).
70487-70488	CT maxillofacial area with/without contrast.
77077	Joint survey, single view, 2 or more joints (joint vibration analysis for TMJ).
90867-90869	Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment codes.
95867-95887	Needle electromyography; cranial nerve supplied muscles and related studies.
96900-96913	Photochemotherapy/actinotherapy codes.
97014-97036	Physical modalities: electrical stimulation, diathermy, infrared, ultrasound, Hubbard tank, etc.
97129-97130	Therapeutic cognitive interventions, initial and additional 15 minutes.
97750	Physical performance test with written report.

Dental/Dento-maxillofacial codes (covered/conditional)mixedCovered

70328-70336	TMJ radiologic exams and arthrography (covered only when used in conjunction with anticipated surgical management).
70486	CT maxillofacial area without contrast (covered only when used in conjunction with anticipated surgical management).
70540-70543	MRI orbit/face/neck sequences (various) (covered only when used in conjunction with anticipated surgical management).
D0320-D0340	Dental TMJ arthrogram, other TMJ films, tomographic survey, panoramic image.
D5931-D5936	Obturator prostheses and related prosthetic/dental device codes.
D7630-D7880	Mandible open/closed reduction and related TMJ surgical dental codes.
D7881	Occlusal orthotic device adjustment.
D9130	Temporomandibular joint dysfunction - non-invasive physical therapies.
D9943-D9946	Occlusal guards.
D9951-D9952	Occlusal adjustment, limited/complete.

HCPCS / J-codes / Device codesHCPCS

E0746	Electromyography (EMG), biofeedback device.
E0720-E0745	TENS and neuromuscular stimulator HCPCS device codes listed.
J0585-J0588	Botulinum toxin type A and other botulinum products per unit.
J0702-J3303	Various injectable corticosteroid and related drug codes listed.
J7321-J7325	Hyaluronan derivatives for intra-articular injection (knee only - see selection criteria).
M0076	Prolotherapy.

ICD-10 diagnosis codes (covered if selection criteria met)ICD-10Covered

M26.601-M26.69	Temporomandibular joint disorders (ICD-10 range).
S02.400-S02.699	Fracture of mandible/malar/maxillary bones (various).
S03.00-S03.02	Dislocation of jaw (closed or open).

HCPCS/Dental codes explicitly not covered for CPB indicationsmixedNot Covered

A4556-A4595	Electrode, lead wires, conductive gel, stimulator supplies (HCPCS not covered for CPB indications).
D5110-D6999	Prosthodontics (removable and fixed) ranges - not covered for CPB indications.
D7899	Unspecified TMD therapy, by report (not covered).
E0720-E0745	TENS/neuromuscular stimulator codes (select HCPCS not covered for CPB indications).

Relevant procedures discussed (no explicit codes listed)mixed

not specified

Image-guided TMJ injections (CT-guided, US-guided), arthrocentesis, arthroscopy, hyaluronic acid injection, corticosteroid injection, cryo-analgesia (procedures discussed without explicit CPT codes in this section).

inv-40: Duration of non-surgical management before surgery — Typical requirement

Minimum documented non-surgical management before surgeryDocumentation of at least 3 months of comprehensive non-surgical management (professional physical therapy, pharmacologic therapy, behavioral therapy, manipulation when appropriate, and reversible intra-oral appliances) is generally required before considering TMJ surgery.

Typical non-surgical modalities requiredIncludes professional physical therapy, pharmacological therapy, behavioral therapy (CBT/relaxation), manipulation for dislocation/fracture when appropriate, and reversible intra-oral appliances.

Exception to waiting periodImmediate surgery may be considered without prior non-surgical management for certain conditions (e.g., bony ankylosis or failed TMJ total joint prosthetic implants).

inv-41: Prolonged intra-oral appliance use — > 6 months requires individual case review

Usual limit for appliance use before reviewProlonged intra-oral appliance use greater than 6 months is not considered medically necessary unless supported by documentation and approved on individual case review.

Coverage note — number of appliancesOnly one oral splint or appliance is considered medically necessary for TMD/TMJ therapy under medical plans.

Adjustments policyAdjustments performed within 6 months of initial appliance therapy are considered medically necessary; adjustments after 6 months are subject to review for necessity and appropriateness.

inv-42: Post-approval study follow-up completeness — 36-month follow-up incomplete (partial reporting percentages)

36-month follow-up completeness — partial prosthesisIn the Christensen post-approval study of the partial TMJ prosthesis, less than half (44%) of 145 subjects had pain, diet restriction, and incisal opening data through 36 months.

36-month follow-up completeness — total prosthesisIn the Christensen post-approval study of the total TMJ prosthesis, just over half of subjects had outcome data at 36 months (pain data 54%; diet restriction data 57%; incisal opening data 50% for affected subjects).

Study cohort sizesPartial prosthesis cohort: 145 subjects (228 joints); Total prosthesis cohort: 78 subjects (127 joints).

Preauthorization, Documentation, and Operational Guidance

Prior Authorization

Precertification required — OMS Patient Management Unit review

All TMJ surgical precertification requests or claims are reviewed by Aetna's Oral and Maxillofacial Surgery (OMS) Patient Management Unit. Requests must include a problem-specific history (Aetna Temporomandibular Disorder Questionnaire), physical examination, TMJ radiographs/diagnostic imaging reports, records documenting 3 to 6 months of non‑surgical management (nature, results, and findings), and the proposed treatment plan; the provider will be notified of the coverage decision after review of all pertinent data.

Include Aetna TMD Questionnaire and complete history of 3–6 months of non-surgical management
Attach physical exam findings, TMJ radiographs/diagnostic imaging reports, and proposed surgical plan

Prior Authorization

Advanced imaging and dental radiology — coverage tied to surgical plan

Advanced TMJ imaging (e.g., 70328, 70330, 70336, 70486, 70540–70543) and certain dental/HCPCS radiology procedures (e.g., D0320–D0340) are covered only when used in conjunction with anticipated surgical management; prior authorization may be required to demonstrate that the imaging is linked to a planned surgical intervention.

Document anticipated surgical management when submitting requests for these imaging CPTs/HCPCS
Coverage is conditional — imaging without surgical indication is not considered medically necessary

Prior Authorization

Prior authorization expected for total TMJ replacement

Total TMJ replacement systems have specific FDA‑approved indications (arthritic conditions, ankylosis, revisions after failed prior treatments); expect prior authorization to require documentation of the indication and failed prior treatments, and supportive pre‑/post‑operative measures as part of the review.

Provide documentation of FDA‑indicated diagnosis (e.g., osteoarthritis, ankylosis) and prior treatment failures
Include device‑specific outcome metrics (pain scores, interincisal opening, functional status) when available

Note

No code-level prior authorization specified in this excerpt

This excerpt does not list specific CPT/HCPCS codes or explicit prior authorization rules for the interventions discussed here; consult the full policy or coding tables for code‑level prior authorization requirements.

Refer to the main policy coding sections for any code‑level prior authorization mandates

Prior Authorization

Prior authorization may be required for intra‑articular biologics or HA

Because randomized trials and protocols for intra‑articular biologics (PRP/PRGF) and hyaluronic acid are heterogeneous and evidence is inconsistent, prior authorization may be required; provide documentation of conservative therapy trials and the detailed treatment plan when requesting coverage.

Document prior conservative therapy and rationale for biologic/HA use
Include specifics of the product/protocol (preparation, dose, number of injections) in requests

Prior Authorization

Prior authorization recommended for intra‑articular and surgical TMJ procedures

For intra‑articular TMJ interventions in juvenile idiopathic arthritis (JIA) and for HA injections or arthrocentesis/arthroscopy in refractory osteoarthritis, obtain prior authorization where required and supply prior imaging and documentation of conservative management trials and clinical indications.

Include MRI or other imaging showing TMJ inflammation/effusion for JIA cases
Provide records of prior conservative management (NSAIDs, splinting, PT, DMARDs where applicable)

Note

Prior authorization not specified in this section

No prior authorization rules appear in this particular section of the excerpt; the document states that some sections contain only references and policy history rather than authorization details.

Check full policy for any plan‑specific prior authorization requirements

Note

Prior authorization — consult main policy for code‑level rules

This section does not list specific CPT/HCPCS codes requiring prior authorization; consult the main policy document and coding tables for code‑level prior authorization requirements.

Use the policy's coding sections to determine whether a particular code requires precertification

Step Therapy

Conservative therapies must be exhausted before elective TMJ surgery

Surgery is considered only after exhaustion of comprehensive non‑surgical management, generally including professional physical therapy, pharmacologic therapy, behavioral therapy (CBT/relaxation), manipulation when appropriate, and reversible intra‑oral appliances for at least three months unless immediate surgery is indicated (e.g., bony ankylosis).

Document trials and outcomes of each non‑surgical therapy in the medical record
Immediate surgery may be justified in select cases (e.g., bony ankylosis, failed prosthesis)

Step Therapy

Conservative‑first approach — document trials of reversible therapies

Non‑surgical conservative therapies — occlusal appliance, physical therapy, medical management, CBT, and biofeedback — should generally be exhausted and documented prior to invasive procedures; appliance trials for intracapsular problems may require wearing the appliance day and night for 2–3 months.

For intracapsular etiologies, document appliance use through day and night (except meals) for a trial of at least 2–3 months
Record response to physical therapy, medications, and behavioral interventions

Note

Conservative, multidisciplinary care preferred before invasive procedures

Evidence summarized in the policy supports a conservative, multidisciplinary/palliative approach prior to additional invasive procedures; irreversible repositioning procedures are generally not supported as medically necessary for TMD.

Prefer reversible, conservative management and document failure before considering irreversible interventions
Irreversible mandibular repositioning procedures lack support and are not considered standard care

Note

No formal step therapy sequencing mandated in this excerpt

The excerpt does not specify formal step therapy sequencing mandates; multiple modalities are compared in trials but no mandated order is provided in this document portion.

Clinical judgment and documented failure of conservative options guide escalation rather than a prescriptive step sequence

Step Therapy

Consider arthrocentesis before adjunct intra‑articular supplements

Some studies suggest arthrocentesis alone effectively reduces pain and improves jaw function; consider arthrocentesis before adding adjunctive intra‑articular supplements such as HA or PRP, and document prior arthrocentesis outcomes when requesting additional injections.

If adjunctive supplements are proposed, include outcomes from prior arthrocentesis to justify escalation
Provide rationale why supplements are expected to add benefit beyond arthrocentesis alone

Documentation Required

Document failed conservative therapy before invasive interventions

Document failure or intolerance to conservative therapy (NSAIDs, splinting, physical therapy, and for JIA, DMARDs) prior to escalating to intra‑articular injections or surgery; include duration, nature of therapy, and objective findings.

Record duration and response to NSAIDs, splint therapy, physical therapy, and any DMARDs used for JIA
Note objective measures (pain scores, MIO) showing inadequate response prior to invasive intervention

Note

No step therapy requirements listed here

No step therapy requirements are provided in this part of the document; the policy emphasizes documentation of prior therapies and clinical justification rather than specifying strict sequencing rules.

Follow clinical criteria and document prior conservative care; check full policy for any plan‑specific protocols

Note

Step therapy rules not included in this section

No step therapy rules are included in these chunks of the excerpt; refer to the complete policy for any plan‑specific step protocols.

Consult the full policy or plan documents for specific step therapy programs

Documentation Required

Required documentation for TMJ surgical review

Submit a problem‑specific history (Aetna TMD Questionnaire), physical examination, TMJ radiographs/diagnostic imaging reports, records documenting 3–6 months of non‑surgical management (nature, results, findings), and the proposed treatment plan when requesting surgical review; lack of these documents may lead to denial.

Include objective measures of function and pain (e.g., MIO, VAS) and results of conservative therapy trials
Attach imaging reports that support the surgical indication

Documentation Required

Document surgical indication when requesting advanced TMJ imaging

Radiologic studies of the TMJ (e.g., CPTs 70328, 70330, 70336 and CT/MRI codes) are indicated and covered only when used in conjunction with anticipated surgical management; documentation should explicitly link imaging to the planned surgical intervention.

State the anticipated surgery and how the imaging will inform the surgical plan when submitting requests
Imaging obtained without a surgical indication may be considered not medically necessary

Documentation Required

Suggested documentation for TMJ replacement — outcome metrics

For TMJ replacement requests, include device‑specific outcome measures and follow‑up data when available (pain scores, diet restriction, interincisal opening), and document prior conservative treatments and prior reconstructive attempts; post‑approval studies and FDA summaries cite these metrics.

Provide pre‑ and post‑operative measures (pain VAS, interincisal opening) and prior treatment history
Report any device‑related events or prior implant failures

Documentation Required

Document validated outcome measures (VAS, MIO) and follow‑up

Clinical studies commonly report validated outcome measures (pain VAS, maximal mouth opening/MIO) and follow‑up time points; when submitting documentation for intra‑articular or surgical interventions, include baseline and follow‑up outcome data using these measures where available.

Include VAS pain scores and MIO measurements at baseline and follow‑up intervals
Specify the procedure performed, doses/volumes, and outcome time points

Documentation Required

Include diagnosis, prior treatments, and rationale for biologic/HA use

When requesting authorization for intra‑articular biologic or viscosupplementation use, include the diagnosis (type of TMD), prior treatments and outcomes, and the clinical rationale for the proposed agent given the variable protocols and limited high‑quality evidence.

Describe prior arthrocentesis/arthroscopy outcomes if performed
Provide justification for selecting PRP/PRGF or HA over standard options

Documentation Required

Essential documentation for image‑guided injections

For image‑guided TMJ injections, record patient age, diagnosis (e.g., JIA with MRI evidence of TMJ inflammation), prior conservative treatments, the specific agent injected (drug and dose), the image guidance modality used (US or CT), and objective post‑procedure outcomes (jaw pain, change in MIO, MRI effusion resolution) to support medical necessity.

Document imaging confirmation of intra‑articular needle placement (CT or US) and any CT confirmation used
List drug name, dose, number of injections, and expected follow‑up assessments

Note

References/policy history — no additional documentation rules here

This portion of the document contains references and policy history and does not list additional provider documentation requirements; check the full policy for any other submission expectations.

Refer to policy history and review dates but use the main policy text for documentation details

Note

Policy history note — consult full policy for requirements

Policy history and review dates are provided in the excerpt; providers should refer to the full policy for comprehensive documentation and prior authorization requirements relevant to specific requests.

Last review: 03/17/2023; Effective date recorded as 08/01/1995
Consult the full CPB for any updates or plan‑specific instructions

Denial Risk

Denial risk — incomplete precertification documentation for TMJ surgery

Requests for TMJ surgery lacking required documentation (Aetna TMD Questionnaire, physical exam, imaging reports, and records of 3–6 months of non‑surgical management) may be denied, because these items are specified as necessary for OMS Patient Management Unit review and coverage decisions.

Failure to document exhaustion of non‑surgical therapies is a common reason for denial
Ensure submitted records clearly describe the nature and results of prior conservative treatments

Denial Risk

Denial risk — advanced imaging without documented surgical indication

Imaging CPTs listed for TMJ (70328, 70330, 70336 and related CT/MRI codes) are covered only when used in conjunction with anticipated surgical management; obtaining these studies without documenting a surgical plan may trigger denial.

Tie imaging orders to an anticipated surgical procedure in the authorization request
Provide imaging reports that explicitly support the surgical indication

Denial Risk

Denial risk — contraindicated patient factors for TMJ prosthesis

Total TMJ replacement devices are contraindicated and not intended for use in patients with active or chronic infection, insufficient bone to support the device, an immature skeleton, or hyper‑functional habits (e.g., clenching/grinding); use in these scenarios may be contraindicated and could lead to denial.

Do not submit replacement requests for patients with active infection or insufficient bone without supporting justification
Document absence of contraindications in the medical record

Note

No authorization/billing rules included in this portion — consult policy

This excerpt focuses on study outcomes and does not specify explicit authorization or billing requirements for certain procedures discussed; absence of code‑level authorization statements in these chunks means providers should consult the full policy or payer portal for billing rules.

When in doubt about authorization for a specific code, contact the payer or check the full CPB coding tables

Denial Risk

Denial risk — insufficient evidence for adjunct intra‑articular therapies

Heterogeneity and methodological inconsistencies in studies of intra‑articular HA and other adjuncts limit conclusions about efficacy; lack of high‑quality evidence may lead to coverage denial unless clear documentation of medical necessity is provided.

Provide strong clinical justification and prior treatment documentation when requesting coverage for HA or PRP
Acknowledge heterogeneity of protocols and include product/preparation details

Documentation Required

Document imaging confirmation of intra‑articular needle placement

When performing image‑guided intra‑articular injections, document imaging confirmation (CT or ultrasound) of intra‑articular needle placement and the clinical indication (e.g., symptomatic TMJ arthritis, JIA) to support medical necessity and reduce risk of denial.

Record modality used (US or CT) and any CT confirmation of intra‑articular needle tip
Include pre‑ and post‑procedure clinical assessments (pain, MIO) in the record

Note

References/policy history — no authorization triggers here

This references and history section contains only administrative information and does not specify authorization or denial triggers; providers should rely on the main policy text for operational requirements.

Use the policy body for submission requirements and the references/history for provenance

Note

Administrative information only — consult main policy for requirements

Administrative disclaimers and copyright information do not contain explicit authorization or denial triggers; refer to the policy content for clinical and billing requirements.

Clinical requirements and coding rules are located in the main policy sections, not in the additional information block

Background and Definitions

Background: Temporomandibular disorders (TMD) encompass pain and/or functional impairment of the masticatory system and temporomandibular joint (TMJ). Diagnostic evaluation relies on history and physical examination with limited imaging (e.g., panoramic radiograph) for routine assessment. Advanced imaging modalities (ultrasound, CT, MRI) are reserved for cases in which surgery is anticipated or to clarify intracapsular pathology. Management ranges from conservative, reversible therapies—occlusal splints, physical therapy, pharmacologic and behavioral treatments—to surgical interventions for intracapsular disease that is refractory to non‑surgical care. The policy emphasizes a conservative‑first approach and documents the typical requirement of at least 3 months of non‑surgical management before considering surgery, unless urgent indications exist.

Key definitions

Short key‑values / thresholds

Policy Dates and References

Note

Policy history: The Clinical Policy Bulletin records the policy effective date as 08/01/1995, the last review on 03/17/2023, and the next scheduled review on 01/11/2024. Providers should consult the full policy text for complete revision history and any amendment details.