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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialAnthem Temporomandibular Coverage Update | OpenPay…
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    ModifiedAnthemPolicy CG-SURG-09

    Temporomandibular Disorders

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    Coverage considerations for surgical and nonsurgical treatments, diagnostic testing, and related procedures for temporomandibular disorders and associated joint or musculoskeletal conditions, including care for children and adolescents.

    Policy Summary
    PayerAnthem
    PolicyTemporomandibular Disorders
    Policy CodePolicy CG-SURG-09
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewNov 6, 2025
    Next Review DateN/A
    Key ActionDocument at least 6 months of nonsurgical treatment before qualifying surgery for clinically significant functional impairment.
    SourceLink
    POLICY UPDATE CHANGES

    The 2026 revision removed surgical HCPCS codes D7810-D7877 from the Coding section because they are not applicable.

    The August 7, 2025 revision removed the medical-necessity statement for intraoral appliances.

    The November 9, 2023 revision added MIRO Therapy to the not-medically-necessary statement.

    The February 11, 2021 revision clarified the surgical medically-necessary criterion and stated that surgical services are not medically necessary when the criteria are not met.

    The May 4, 2017 revision added modified condylotomy to the surgical procedures considered medically necessary when criteria are met.

    The November 10, 2022 revision moved content related to iontophoresis to policy CG-MED-28.

    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.

    6 monthsMinimum nonsurgical treatment before qualifying surgery
    Under 18Age requiring skeletal-growth documentation when applicable
    9Diagnostic tests and procedures considered not medically necessary for TMD evaluation
    D7810-D7877Surgical HCPCS code range removed in this revision
    2025-11-06Most recent substantive policy revision

    Medical Necessity and Excluded Services

    Not Medically Necessary Services

    The following services are considered <strong>not medically necessary</strong> for temporomandibular disorders.

    ONE of the following

    • Surgical procedures for temporomandibular disorders when the applicable medical-necessity criteria are not met.
    • Electrogalvanic stimulation (EGS).
    • Jaw motion rehabilitation systems.
    • Mandibular image-guided rehabilitative orthopedics (MIRO Therapy®).
    • Occlusal equilibration, bite adjustment, or irreversible occlusion therapy.
    • Computerized mandibular scan intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning.
    • Intra-oral tracing or gothic arch tracing intended to document deviations in jaw positioning.
    • Electromyography, including percutaneous or surface electrode methods.
    • Kinesiography.
    • Laryngeal function studies.
    • Rhinomanometry.
    • Somatosensory testing or neuromuscular junction testing.
    • Swallowing studies or tests.
    • Thermography.

    Surgical procedures for temporomandibular disorders are considered not medically necessary when the applicable surgical medical-necessity criteria are not met.

    Nonsurgical treatments considered not medically necessary for temporomandibular disorders include, but are not limited to:

    • Electrogalvanic stimulation (EGS).

    • Jaw motion rehabilitation systems.

    • Mandibular image-guided rehabilitative orthopedics, also known as MIRO Therapy®.

    • Occlusal equilibration, bite adjustment, or irreversible occlusion therapy.

    The following diagnostic tests and procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

    • Computerized mandibular scan, intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning.

    • Intra-oral tracing or gothic arch tracing, intended to document deviations in jaw positioning.

    • Electromyography, including percutaneous or surface electrode methods.

    • Kinesiography.

    • Laryngeal function studies.

    • Rhinomanometry.

    • Somatosensory testing or neuromuscular junction testing.

    • Swallowing studies or tests.

    • Thermography.

    For the TMD and related diagnosis codes listed in the coding section, the following procedure codes are considered not medically necessary, or are not medically necessary when the code describes a procedure designated as not medically necessary in the Clinical Indications section:

    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).

    Related diagnosis codes include G44.89, M19.09, M19.91, M26.50-M26.59, M26.601-M26.69, M79.10-M79.12, and S03.00XA-S03.03XS.

    The November 9, 2023 revision added mandibular image-guided rehabilitative orthopedics (MIRO Therapy®) to the statement identifying nonsurgical treatments for temporomandibular disorders as not medically necessary. The complete revision wording is unavailable in the source.

    The source indicates that surgical procedures are not medically necessary when the applicable medical-necessity criteria are not met. The complete criteria and full wording for this historical revision are unavailable.

    Covered, Excluded, and Historical Codes

    CPT codes when services may be medically necessary when criteria are metCPTCovered
    20605Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance [when specified as temporomandibular joint aspiration]
    20606Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; with ultrasound guidance, with permanent recording and reporting [when specified as temporomandibular joint aspiration]
    21010Arthrotomy, temporomandibular joint
    21050Condylectomy, temporomandibular joint (separate procedure)
    21060Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
    21073Manipulation of temporomandibular joint(s), therapeutic, requiring an anesthesia service
    21110Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
    21116Injection procedure for temporomandibular joint arthrography
    21210Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
    21240Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
    1–10 of 14
    1/2
    HCPCS codes when services may be medically necessary when criteria are metHCPCSCovered
    D7899Unspecified TMD therapy, by report
    ICD-10-PCS procedure codes when services may be medically necessary when criteria are metICD-10Covered
    0RBC0ZZExcision of right temporomandibular joint, open approach
    0RBC3ZZExcision of right temporomandibular joint, percutaneous approach
    0RBC4ZZExcision of right temporomandibular joint, percutaneous endoscopic approach
    0RBD0ZZExcision of left temporomandibular joint, open approach
    0RBD3ZZExcision of left temporomandibular joint, percutaneous approach
    0RBD4ZZExcision of left temporomandibular joint, percutaneous endoscopic approach
    0RQC0ZZ-0RQC4ZZRepair right temporomandibular joint; includes 0RQC0ZZ, 0RQC3ZZ, and 0RQC4ZZ
    0RQD0ZZ-0RQD4ZZRepair left temporomandibular joint; includes 0RQD0ZZ, 0RQD3ZZ, and 0RQD4ZZ
    0RSC04Z-0RSCXZZReposition right temporomandibular joint; includes 0RSC04Z, 0RSC0ZZ, 0RSC34Z, 0RSC3ZZ, 0RSC44Z, 0RSC4ZZ, 0RSCX4Z, and 0RSCXZZ
    0RSD04Z-0RSDXZZReposition left temporomandibular joint; includes 0RSD04Z, 0RSD0ZZ, 0RSD34Z, 0RSD3ZZ, 0RSD44Z, 0RSD4ZZ, 0RSDX4Z, and 0RSDXZZ
    1–10 of 12
    1/2
    ICD-10 diagnosis codes when services may be medically necessary when criteria are metICD-10Covered
    G44.89Other headache syndrome
    M19.09Primary osteoarthritis, other specified site
    M19.91Primary osteoarthritis, unspecified site
    M26.50-M26.59Dentofacial functional abnormalities
    M26.601-M26.69Temporomandibular joint disorders
    M79.10-M79.12Myalgia, unspecified; mastication muscle; auxiliary muscles, head and neck
    S03.00XA-S03.03XSDislocation of jaw
    HCPCS codes also considered not medically necessary for TMD and related diagnosesHCPCSNot Covered
    D9950Occlusion analysis- mounted case
    D9951Occlusal adjustment- limited
    D9952Occlusal adjustment- complete
    E1700Jaw motion rehabilitation system
    E1701Replacement cushions for jaw motion rehabilitation system, package of 6
    E1702Replacement measuring scales for jaw motion rehabilitation system, package of 200
    Removed surgical HCPCS codesHCPCS
    D7810-D7877Surgical HCPCS codes removed from the Coding section; not applicable.
    Historical HCPCS coding changesHCPCS
    D7873-D7877Code descriptors were updated in the November 14, 2024 revision.
    D7880Removed from the Coding section in the August 7, 2025 revision because it was no longer addressed.
    Historical procedure and HCPCS coding referencesmixed
    97033Added in the March 21, 2019 revision; removed in the November 10, 2022 revision when iontophoresis content moved to CG-MED-28.
    D9130Added in the March 21, 2019 revision; removed in the November 10, 2022 revision because it was no longer addressed.
    D9920Added in the March 21, 2019 revision; removed in the November 10, 2022 revision because it was no longer addressed.
    D9940Removed in the March 21, 2019 revision because the code was deleted on December 31, 2018.
    S8262Removed in the July 1, 2015 revision because the code was deleted on June 30, 2015.
    Historical ICD-10-CM coding referencesICD-10
    M19.09Added with the October 1, 2020 ICD-10-CM coding update.
    S03.00XA-S03.03XSCorrected in the October 1, 2019 ICD-10-CM coding update.
    M79.10-M79.12Added in the September 20, 2018 ICD-10-CM coding update, replacing M79.1.
    M79.1Replaced by M79.10-M79.12 in the September 20, 2018 ICD-10-CM coding update.
    Refractory nonsurgical treatment
    Minimum durationAt least 6 months
    Treatment typeNonsurgical treatment
    Applies whenClinically significant functional impairment is refractory to treatment before qualifying surgery
    Serial cephalometric observation
    PopulationIndividuals under the age of 18 years

    Documentation and Denial-Prevention Checklist

    Documentation Required

    Document 6 Months of Refractory Nonsurgical Treatment

    Before qualifying surgical treatment, document a clinically significant functional impairment that has remained refractory despite at least 6 months of nonsurgical treatment.

    • Document the nonsurgical treatment provided and the duration of treatment.
    • Record the persistent clinically significant functional impairment and its impact.
    Documentation Required

    Support Structural Joint Pathology

    Document temporomandibular joint internal derangement or another structural joint disorder, supported by radiographic evidence of temporomandibular joint pathology.

    • Examples of radiographically supported pathology include arthritis, bone cyst, fracture, meniscal abnormality, or tumors.
    Documentation Required

    Temporomandibular Disorders

    Temporomandibular disorders encompass conditions involving the temporomandibular joints, masticatory muscles, and contiguous tissues. Presentations may include jaw or facial pain, headaches, earaches, restricted mouth opening, and joint sounds.

    Policy Terms

    Analgesics
    Medication typeMedications
    Primary purposeProvide pain relief
    Clinical usePain relief in the treatment of temporomandibular disorders
    Arthroplasty
    Procedure typeSurgery
    PurposeRelieve pain and restore range of motion
    Joint interventionRealigning or reconstructing a joint
    Policy Summary
    PayerAnthem
    PolicyTemporomandibular Disorders
    Policy CodePolicy CG-SURG-09
    Change TypeModified
    Effective DateOctober 1, 2026
    Last ReviewNov 6, 2025
    Next Review DateN/A
    Key ActionDocument at least 6 months of nonsurgical treatment before qualifying surgery for clinically significant functional impairment.
    SourceLink
    On This Page
    Medical Necessity and Excluded ServicesCovered, Excluded, and Historical CodesDocumentation and Denial-Prevention ChecklistTemporomandibular DisordersPolicy Terms
    Observation methodSerial cephalometrics
    Required findingNo change in facial bone relationships over the last 3- to 6-month period

    Document Skeletal Growth Completion

    For individuals younger than 18 years, document completion of skeletal growth before surgery is considered medically necessary.

    • Long-bone x-ray; or
    • Serial cephalometrics showing no change in facial bone relationships over the preceding 3- to 6-month period.
    Documentation Required

    Establish Qualifying Pain or Functional Impairment

    Document at least one qualifying indication: temporomandibular joint pain due to a maxillary or mandibular skeletal deformity, or clinically significant functional impairment refractory to at least 6 months of nonsurgical treatment.

    • Link the temporomandibular joint pain to the skeletal deformity when that pathway is used.
    • Describe the functional impairment, failed nonsurgical care, and refractory status when that pathway is used.
    Denial Risk

    Surgery Criteria Must Be Met

    Surgical treatment for temporomandibular disorders is not medically necessary when the required structural pathology, skeletal-growth documentation, or qualifying pain or functional-impairment criteria are not satisfied.

    • Verify that all structural and applicable age-related growth requirements are documented.
    • Verify that at least one qualifying pain or functional-impairment pathway is met.
    Denial Risk

    Specified Nonsurgical Treatments Excluded

    The following nonsurgical treatments are not medically necessary when used to treat temporomandibular disorders.

    • Electrogalvanic stimulation (EGS).
    • Jaw motion rehabilitation systems.
    • Mandibular image-guided rehabilitative orthopedics (MIRO Therapy®).
    • Occlusal equilibration, bite adjustment, or irreversible occlusion therapy.
    Denial Risk

    Specified Diagnostic Testing Excluded

    The following diagnostic tests and procedures are not medically necessary when used to diagnose or evaluate temporomandibular disorders.

    • Computerized mandibular scan intended to document occlusal deviations or muscle activity related to mandibular movement or positioning.
    • Intra-oral tracing or gothic arch tracing.
    • Electromyography, including percutaneous or surface electrode methods.
    • Kinesiography.
    • Laryngeal function studies.
    • Rhinomanometry.
    • Somatosensory testing or neuromuscular junction testing.
    • Swallowing studies or tests.
    • Thermography.
    Billing Rule

    Related Procedure and Device Codes Excluded

    For temporomandibular disorders and related diagnoses, the following procedure and device codes are not medically necessary, including when the service describes an excluded occlusal or jaw-motion rehabilitation procedure.

    • 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.
    Craniomandibular disorder (CMD)
    TerminologyA dental term
    Conditions describedDiseases or disorders of the muscles of the head and neck
    Specific muscle focusThe masticatory (chewing) muscles
    Disc
    TerminologyShortened terminology
    May refer toAn intervertebral disc or a TMJ disc
    Tissue functionA disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones
    Mandible
    Anatomical structureBone
    LocationThe lower jaw
    Related jointForms the jaw component of the temporomandibular joint
    Meniscus
    Tissue typeCartilage pad
    LocationBetween the two joint surfaces within the TMJ
    FunctionActs as a smooth surface for the joint to move on
    Modified condylotomy
    Procedure typeExtra-articular surgical procedure
    Clinical purposeUsed to manage TMJ dysfunction
    Joint-space effectIncreases joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence
    Occlusal orthotic device
    Device typeIntraoral appliance
    CharacteristicsReversible and removable
    ExampleA splint
    Orthodontics
    Professional fieldA specialty of dentistry
    Primary focusPrevention of abnormally positioned or aligned teeth
    Corrective focusCorrection of abnormally positioned or aligned teeth
    Temporal bone
    Bone typeA large, irregular bone
    LocationSituated at the base and side of the skull
    ConnectionConnected with the mandible via the TMJ
    Temporomandibular joint (TMJ)
    Joint functionHinges the mandible to the temporal bone of the skull
    UseMoves whenever a person eats, drinks, or talks
    Anatomical descriptionOne of the most frequently used joints in the entire body