ModifiedBlue Cross Blue Shield - MassachusettsPolicy 035

Temporomandibular Joint Disorder (TMJD) — diagnosis and treatment

Policy governing coverage, prior authorization, and investigational determinations for diagnostic, nonsurgical, and surgical treatments of temporomandibular joint disorder for Blue Cross Blue Shield Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyTemporomandibular Joint Disorder (TMJD) — diagnosis and treatment

Policy CodePolicy 035

Change TypeMaterial revisions: coding and investigational additions

Effective Date

Next Review Date

Key ActionObtain prior authorization via Authorization Manager for surgical TMJ procedures and enter the servicing surgeon's NPI and the facility NPI on the submission.

SourceLink

POLICY UPDATE CHANGES

CPT codes 21073 and 21116 were removed and prior authorization is no longer required for those codes.

Botulinum toxin A was added as investigational under nonsurgical treatments for TMJD.

Prior authorization requests may be submitted using Authorization Manager and instructions were clarified.

Investigational policy statement modified to include dextrose prolotherapy.

Diagnostic: No prior authDiagnostic procedures generally do not require prior authorization

Surgical: Prior auth requiredPrior authorization required for surgical treatments

5 yrs

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Coverage Determinations and Criteria

Covered when criteria met

Covered when ALL of the following are met, summarized by service type:

Diagnostic procedures: Diagnostic X-ray, tomograms, and arthrograms do not require prior authorization. CT or MRI may be medically necessary primarily for pre-surgical evaluations; cephalograms/pantograms are reviewed individually. Several diagnostic tests are considered investigational (for example, kinesiography, surface EMG, thermography, joint vibration analysis, ultrasound, and arthroscopy for purely diagnostic purposes).

From Diagnostic Procedures section; imaging generally reserved for severe or pre-surgical evaluation.

Nonsurgical treatments: Intra-oral removable appliances (including fabrication, insertion, adjustment), pharmacologic therapy (anti-inflammatory, muscle relaxants, analgesics), splint therapy including mandibular orthopedic repositioning appliance (MORA) with measuring/fabrication/adjustment, and physical therapy may be considered medically necessary and do not require prior authorization. Unless otherwise specified, reasonable replacement frequency for an oral appliance is once every five years. Certain nonsurgical therapies are considered investigational and not covered (for example, iontophoresis, electrogalvanic stimulation, biofeedback, ultrasound, devices to maintain range of motion, orthodontic services, TENS, hyaluronic acid, PENS, platelet concentrates, dextrose prolotherapy, and botulinum toxin A).

From Nonsurgical Treatments section; replacement frequency per Durable Medical Policy note.

Surgical treatments: Arthrocentesis, arthroscopy for internal derangement or degenerative disease after failed conservative treatment, manipulation for reduction of fracture or dislocation, and open surgical procedures (eg, arthroplasties, condylectomies, meniscus/disc procedures) may be medically necessary but require prior authorization per product rules.

From Surgical Treatments section; prior authorization required for surgical TMJ procedures.

Investigational treatments

Investigational treatments and policy history additions (items considered investigational and not covered):

Investigational additions: Botulinum toxin A has been added as investigational under nonsurgical treatments (effective 7/1/2023). Dextrose prolotherapy was added to the investigational policy statement (effective 7/1/2022).

As recorded in Policy History.

Other investigational treatments: The policy lists additional nonsurgical and diagnostic techniques as investigational (not considered medically necessary) including iontophoresis, electrogalvanic stimulation, biofeedback, ultrasound, devices promoted to maintain joint range of motion, orthodontic services, TENS, PENS, hyaluronic acid, platelet concentrates, and joint diagnostic tests such as kinesiography, surface EMG, thermography, somatosensory testing, and joint vibration analysis.

From Diagnostic and Nonsurgical Treatments sections.

The policy identifies a number of diagnostic tests and nonsurgical techniques that are considered investigational and therefore not covered for the diagnosis or treatment of temporomandibular joint disorder (TMJD). These specifically include kinesiography, electromyography (including surface EMG), thermography, somatosensory testing, neuromuscular junction testing, ultrasound imaging/sonogram, joint vibration analysis, muscle testing, intra-oral tracing or gnathic arch tracing, computerized mandibular scan, range of motion measurements, and arthroscopy of the TMJ when performed for purely diagnostic purposes. The nonsurgical investigational list further includes iontophoresis, electrogalvanic stimulation, biofeedback, devices promoted to maintain joint range of motion and to develop jaw muscles, dental restorations/prostheses, orthodontic services, transcutaneous electrical nerve stimulation (TENS), hyaluronic acid, percutaneous electrical nerve stimulation (PENS), platelet concentrates, dextrose prolotherapy, and botulinum toxin A.

The policy clarifies prior authorization and exclusion approaches relevant to coverage: diagnostic procedures and nonsurgical treatments do not require prior authorization, while surgical TMJ treatments require prior authorization per product rules. Operational history notes that prior authorization requests may be submitted using Authorization Manager, and that CPT codes 21073 and 21116 were removed from prior authorization requirements effective 4/1/2025. The policy also states that specific investigational techniques listed are not covered (see investigational lists), and that the reasonable replacement frequency for oral appliance durable medical equipment is once every five years unless otherwise specified.

Evidence summaries indicate that several diagnostic modalities lack sufficient diagnostic accuracy for TMJD. Systematic reviews of ultrasound, surface EMG, and joint vibration analysis did not demonstrate accurate identification of TMJD and had methodological limitations; therefore the evidence is insufficient to support their routine use for diagnosis. For nonsurgical therapies, randomized controlled trials and systematic reviews provide mixed results: intraoral appliances and some pharmacologic agents have supportive evidence for improving symptoms, but other interventions such as acupuncture, hyaluronic acid, platelet concentrates, and dextrose prolotherapy have small, methodologically limited studies with inconsistent outcomes, supporting their investigational or non-covered status. Imaging modalities such as CT and MRI may be medically necessary primarily for pre-surgical evaluations, while plain radiographs (diagnostic X-ray, tomograms, arthrograms) generally do not require prior authorization.

The policy makes investigational determinations for several nonsurgical interventions, indicating they are not considered medically necessary. Notable investigational items added or highlighted in the policy history include dextrose prolotherapy (added effective 7/1/2022) and botulinum toxin A (added as investigational effective 7/1/2023). The investigational list also includes platelet concentrates, hyaluronic acid, PENS, iontophoresis, biofeedback, TENS, and electrogalvanic stimulation. These determinations reflect the evidence summaries that show insufficient or inconsistent data to demonstrate a net health benefit for these treatments.

Coding and Durable Medical Equipment Rules

CPT Codes (selected)CPT

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
29804	Arthroscopy, temporomandibular joint; surgical

Affected CPT codes (prior authorization change)CPT

21073	CPT code removed from prior authorization requirements
21116	CPT code removed from prior authorization requirements

inv-09: Durable medical equipment replacement frequency — once every five years

Durable medical equipment replacement frequencyReasonable replacement frequency for a durable medical device (oral appliance) is once every five years unless otherwise specified.

Effective policy noteThis replacement frequency clarification was added to the policy history (note dated 11/2022) and referenced in subsequent reviews.

Related payment policySee Durable Medical Policy Payment Policy for additional billing/payment details.

Prior Authorization, Submission, and Documentation

Prior Authorization

Prior Authorization Required for Surgical TMJD Procedures

Prior authorization is required for surgical treatments of temporomandibular joint disorders (TMJD). This includes, but is not limited to, arthrocentesis, arthroscopy, arthroplasty, condylectomy, meniscus or disc plication, and disc removal. Prior authorization applies to surgical procedures whether performed inpatient or outpatient as specified by product. Diagnostic procedures and nonsurgical treatments do not require prior authorization.

Prior authorization required for surgical TMJD procedures (examples: arthrocentesis, arthroscopy, arthroplasty, condylectomy, meniscus/disc procedures).
Prior authorization applies per product rules for outpatient vs inpatient settings; inpatient procedures require precertification/preauthorization for all products.
CPT codes 21073 and 21116 were removed from prior authorization requirements effective 4/1/2025 (policy history).

Note

Conservative Therapy Recommended Prior to Surgery

Conservative (nonsurgical) therapy is generally recommended and expected prior to consideration of surgical intervention for TMJD unless contraindicated. Examples of nonsurgical therapies that do not require prior authorization include intra-oral removable oral appliances (fabrication, insertion, adjustment), splint therapy (including mandibular orthopedic repositioning appliance), pharmacologic management (anti-inflammatories, muscle relaxants, analgesics), physical therapy, and other noninvasive modalities. Note that several nonsurgical modalities are considered investigational and are not recommended (for example, iontophoresis, biofeedback, ultrasound, TENS, platelet concentrates, prolotherapy, botulinum toxin A, etc.).

Clinical Background

Temporomandibular joint disorder (TMJD) is a group of conditions affecting the temporomandibular joint and surrounding tissues that is often a diagnosis of exclusion. Diagnosis typically relies on patient history and physical examination, dental records, and focused imaging when indicated. Common symptoms include jaw clicking, pain, limited opening or locking, tinnitus, and referred pain to the head, neck, or ears. Imaging such as CT or MRI is generally reserved for pre-surgical evaluation or when findings on exam suggest structural pathology; many cases are managed conservatively with splint therapy, pharmacologic treatment, and physical therapy.

Key Definitions and Acronyms

inv-19: TMJD — Definition and core features

DefinitionTemporomandibular joint disorder (TMJD) is often a diagnosis of exclusion involving the temporomandibular joint and surrounding tissues, based on history, physical examination, and review of dental records.

Core featuresSymptoms vary and include jaw clicking, headaches, jaw closing or locking (trismus), displaced disc, pain in ears/neck/arms/spine, tinnitus, and bruxism (teeth clenching/grinding).

Imaging and testingDiagnostic testing and radiologic imaging are generally recommended only for individuals with severe or chronic symptoms; diagnostic criteria have been developed and validated for clinical and research use.

inv-20: DC/TMD — Diagnostic Criteria for Temporomandibular Disorders reference

DC/TMD referenceDiagnostic Criteria for Temporomandibular Disorders (DC/TMD) — developed for clinical and research applications and cited in the policy references (Ohrbach et al., J Oral Facial Pain Headache; Schiffman & Ohrbach executive summary).