CurrentBlue Cross Blue Shield - MassachusettsPolicy 035

Temporomandibular Joint Disorder (TMJD) — Diagnostics and Treatments

This policy governs medical necessity, prior authorization, and coding for diagnostic, nonsurgical, and surgical management of temporomandibular joint disorder for Blue Cross Blue Shield - Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyTemporomandibular Joint Disorder (TMJD) — Diagnostics and Treatments

Policy CodePolicy 035

Change TypeInvestigational updates and clarifications (2020–2022)

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests for surgical TMJ treatments via Authorization Manager, including facility NPI and surgeon's NPI.

SourceLink

POLICY UPDATE CHANGES

Investigational policy statement modified to include dextrose prolotherapy.

Investigational statement modified to include platelet concentrates.

Investigational statement on acupuncture as non-surgical treatment of TMJD was removed.

Splint therapy, including a mandibular orthopedic repositioning appliance (MORA) and measuring, fabricating and adjusting the splint, was added under nonsurgical treatments of TMJD.

Diagnostic procedures and nonsurgical treatments do not require prior authorization.

Prior authorization information clarified for PPO plans.

No PAdiagnostic procedures PA requirement

No PAnonsurgical treatments PA requirement

PA req'dsurgical treatments PA requirement

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Coverage Criteria for TMJD

Covered with criteria

Covered when ALL of the following apply:

Diagnostic procedures: Diagnostic x-rays, tomograms, arthrograms, computed tomography (CT) or magnetic resonance imaging (MRI) (generally reserved for pre‑surgical evaluations), cephalograms and pantograms (to be reviewed individually)

Certain diagnostic procedures are considered investigational (eg, electromyography including surface EMG, kinesiography, thermography, neuromuscular junction testing, somatosensory testing, transcranial or lateral skull x‑rays, intra‑oral tracing/gnathic arch tracing, ultrasound imaging/sonogram, arthroscopy for purely diagnostic purposes, joint vibration analysis)

Nonsurgical treatments: Intra‑oral removable prosthetic devices/appliances (fabrication, insertion, adjustment), splint therapy including mandibular orthopedic repositioning appliance (MORA) with measuring/fabricating/adjusting, pharmacologic treatment (analgesics, muscle relaxants, anti‑inflammatories), and physical therapy may be medically necessary

Several nonsurgical interventions are considered investigational (eg, electrogalvanic stimulation, iontophoresis, biofeedback, ultrasound, devices to maintain joint range of motion, orthodontic services, dental restorations/prostheses, TENS, PENS, hyaluronic acid, platelet concentrates, dextrose prolotherapy, botulinum toxin A)

Surgical treatments: Arthrocentesis; manipulation for reduction of TMJ fracture or dislocation; arthroscopic surgery for objectively demonstrated internal derangements (displaced discs) or degenerative joint disease after failed conservative treatment; and open surgical procedures (eg, arthroplasties, condylectomies, meniscus/disc plication or removal) for congenital anomalies, trauma, or disease after failed conservative treatment may be medically necessary

Prior authorization is required for surgical treatments

The policy identifies several diagnostic and nonsurgical techniques as investigational for temporomandibular joint disorder (TMJD). Diagnostic procedures listed as investigational include electromyography (EMG), including surface EMG, kinesiography, thermography, neuromuscular junction testing, somatosensory testing, transcranial or lateral skull x-rays, intra-oral tracing/gnathic arch tracing, muscle testing, standard dental radiographic procedures, range of motion measurements, computerized mandibular scan, ultrasound imaging/sonogram, arthroscopy of the TMJ for purely diagnostic purposes, and joint vibration analysis.

For nonsurgical treatments the policy lists the following as investigational: electrogalvanic stimulation, iontophoresis, biofeedback, ultrasound, devices promoted to maintain joint range of motion and to develop jaw muscles, orthodontic services, dental restorations/prostheses, transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), hyaluronic acid, platelet concentrates, dextrose prolotherapy, and botulinum toxin A.

Policy history documents revisions to the investigational statements: an investigational policy statement was modified to include dextrose prolotherapy effective 7/1/2022, and an earlier revision added platelet concentrates as investigational effective 7/1/2021. The policy also notes that the investigational statement on acupuncture was removed effective 1/1/2020.

These modifications mean that, per the policy, both dextrose prolotherapy and platelet concentrates are explicitly identified in the investigational/non-medically necessary sections, while acupuncture is no longer listed as investigational in the 2020 update.

The summary of evidence indicates that there is insufficient evidence to determine net health benefit for several diagnostic technologies used in TMJD, including ultrasound, surface electromyography, and joint vibration analysis. Systematic reviews of diagnostic test studies did not demonstrate accurate identification of TMJD for these techniques, and many studies had methodological limitations.

Consistent with that evidence assessment, the policy lists these technologies among those considered investigational for diagnostic purposes and therefore not established as improving net health outcomes for TMJD diagnosis.

The policy contains investigational (not medically necessary) statements for certain treatments, specifically noting dextrose prolotherapy and platelet concentrates as investigational interventions for TMJD following recent revisions (platelet concentrates effective 7/1/2021; dextrose prolotherapy effective 7/1/2022).

These investigational designations mean the available evidence was judged insufficient to demonstrate a consistent net health benefit for these injection-based therapies for TMJD, and they are therefore not considered medically necessary per the policy.

Coding and Procedure Codes

Covered CPT Codes (surgical procedures)CPTCovered

21010	Arthrotomy, temporomandibular joint.
21050	Condylectomy, temporomandibular joint (separate procedure).
21060	Meniscectomy, partial or complete, temporomandibular joint.
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.
29800	Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure).
29804	Arthroscopy, temporomandibular joint, surgical.

Provider Actions, Prior Authorization, and Submission

Prior Authorization

Prior Authorization Required for Surgical and Inpatient Procedures

Prior authorization is required for surgical treatments of temporomandibular joint disorders (TMJD). This includes arthrocentesis, arthroscopic surgery, open surgical procedures (e.g., arthroplasties, condylectomies, meniscus/disc procedures), and manipulation for reduction of fracture or dislocation of the TMJ. Inpatient surgical services require precertification/preauthorization for all products.

Surgical treatments (inpatient or outpatient) require prior authorization.
Inpatient procedures: precertification/preauthorization is required for all products.
Outpatient procedures: prior authorization is required for surgical treatments across Commercial HMO/POS, Commercial PPO/Indemnity, Medicare HMO Blue, and Medicare PPO Blue.

Note

Prior Authorization Not Required for Diagnostic and Nonsurgical Treatments

Diagnostic procedures and nonsurgical treatments do not require prior authorization. Examples of nonsurgical treatments considered medically necessary include intra-oral removable prosthetic devices/appliances, splint therapy including mandibular orthopedic repositioning appliance (MORA) with measuring/fabrication/adjustment, pharmacologic treatment, and physical therapy. Several nonsurgical treatments are considered investigational (see policy for full list).

Background

Temporomandibular joint disorder (TMJD) refers to a group of disorders causing pain in the temporomandibular joint and surrounding tissues. Diagnosis is typically clinical—based on history and physical examination—and often by exclusion; imaging and specialized diagnostic testing are generally reserved for severe or chronic symptoms or for pre-surgical evaluation.

Conservative, noninvasive treatments (for example, intra-oral appliances, splint therapy including a mandibular orthopedic repositioning appliance (MORA), pharmacologic therapy, and physical therapy) are considered first-line. The policy notes that diagnostic tests such as ultrasound, surface EMG, and joint vibration analysis have insufficient evidence supporting diagnostic accuracy, and several minimally invasive or injection treatments (for example, platelet concentrates and dextrose prolotherapy) are designated investigational.

Definitions and Diagnostic Criteria

Temporomandibular joint disorder (TMJD) — definition & common symptoms

DefinitionGroup of disorders characterized by pain in the temporomandibular joint and surrounding tissues; initial conservative therapy is generally recommended.

Common symptomsJaw clicking or clicking sounds in the jaw; headaches; pain in ears, neck, arms, or spine; tinnitus; trismus (jaw locking or limited opening); bruxism (clenching or grinding).

Typical diagnostic approachOften a diagnosis of exclusion based on history, physical exam, and dental records; diagnostic testing and imaging generally reserved for severe or chronic symptoms.

DC/TMD — Diagnostic Criteria for Temporomandibular Disorders

Full nameDiagnostic Criteria for Temporomandibular Disorders (DC/TMD)

Purpose