Currentblue cross blue shield - michiganPolicy N/A

Temporomandibular joint (TMJ) appliance benefit

Governs coverage, reimbursement, billing, and member cost-sharing for temporomandibular joint appliances under select Medicare Plus Blue Group PPO (MPSERS) plans in Michigan.

Policy Summary

Payerblue cross blue shield - michigan

PolicyTemporomandibular joint (TMJ) appliance benefit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConfirm member belongs to the MPSERS Medicare Plus Blue Group PPO that selected the enhanced TMJ appliance benefit before billing and apply group-determined reimbursement and member cost-share.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MPSERS onlyEnhanced benefit availability restricted to MPSERS custom group

No Original Medicare coverageOriginal Medicare does not pay for TMJ appliances

Payment = lesser of allowed or chargeReimbursement method (minus member cost-share)

Discontinued 1/1/2014Benefit discontinued

CMS1500/UB04/837Billing guidance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Temporomandibular Joint (TMJ) Appliance Coverage Criteria

TMJ appliance coverage criteria

Coverage is limited to members of the MPSERS custom Medicare Plus Blue Group PPO that selected this enhanced benefit and is subject to group-determined scope, restrictions, and reimbursement.

Member must belong to the MPSERS Medicare Plus Blue Group PPO that selected the TMJ appliance enhanced benefit.

Eligible provider: Dentist.

Payable location: No restrictions specified.

Frequency: Refer to code D9940 for frequency; specific frequency limits are determined by the group and the MA enhanced benefits fee schedule.

Age/diagnosis restrictions apply; specific restrictions are determined by the group.

Reimbursement: Provider will be paid the lesser of the MA enhanced benefit allowed amount (from the MA enhanced benefits fee schedule) or the provider's charge, minus the member's cost-share; this payment represents payment in full and providers are not allowed to balance bill the member for the difference.

Member cost-sharing: Collect applicable Medicare Plus Blue Group PPO cost-share (copayment, coinsurance, deductible) at time of service when possible; if the member elects a noncovered service, the member is responsible for the entire charge.

Billing: Submit claims on CMS 1500, UB-04 or the 837 equivalent; follow Medicare Advantage PPO billing requirements and report CPT/HCPCS and diagnosis codes to the highest specificity; verify member benefits via web-DENIS or CAREN as needed.

Codes and Payment Calculation

Referenced dental codeCPTCovered

D9940

Occlusal guard—diagnostic code referenced for frequency/coverage conditions

Payment calculation

Payment methodProvider is paid the lesser of the MA enhanced benefit allowed amount (from the MA enhanced benefits fee schedule) or the provider's charge, minus the member's cost-share.

Allowed amount sourceMA enhanced benefits fee schedule on bcbsm.com/provider/ma.

Balance billingThis payment represents payment in full; providers are not allowed to balance bill the member for the difference.

Eligibility, Billing, and Provider Responsibilities

Prior Authorization

Eligibility and benefit determination — select MPSERS Medicare Plus Blue Group PPO plans only

Coverage limited to members enrolled in select Medicare Plus Blue Group PPO plans under the MPSERS custom group; Original Medicare (Part A and B) does not cover TMJ appliances so group-selected enhanced benefit governs eligibility, scope, reimbursement, maximums, and member cost-sharing. Verify member plan is a Medicare Plus Blue Group PPO MPSERS plan that included the TMJ appliance enhanced benefit before providing or billing for services. BCBSM discontinued offering this enhanced benefit for new designs effective January 1, 2014; confirm the member’s plan effective dates and benefit selections. Providers must confirm eligibility and any applicable group-determined limitations (including age/diagnosis restrictions, frequency limits, and maximum allowable payment amounts) prior to treatment. Treating provider must bill as a dentist, use the payable location without restriction, and follow any coding or documentation requirements specified by the group.

Confirm member is enrolled in the MPSERS Medicare Plus Blue Group PPO plan that selected the TMJ appliance enhanced benefit
Verify plan effective date and whether the enhanced benefit was in force for the member (BCBSM discontinued offering this benefit for new designs effective 2014-01-01)
Obtain and document medical necessity per group-defined age/diagnosis restrictions before providing appliance
Verify frequency limits and any maximum allowable payment amounts set by the group
Bill under dental provider (Dentist) taxonomy; use location of service with no payable-location restrictions

Key Definitions

TMJ — definition

DefinitionTemporomandibular joint (TMJ): the joint located in front of the ear where the skull and mandible (lower jaw) articulate; it allows the mandible to move and function.

Associated structuresTMJ disorders affect the temporomandibular joint and associated anatomical structures.

Clinical manifestationsSymptoms may include pain and/or dysfunction of the TMJ apparatus and adjacent structures, ranging from low to moderate severity.

Original Medicare exclusions

§1862(a)(1) exclusionOriginal Medicare excludes items and services not demonstrated to be reasonable and necessary for diagnosis and treatment under §1862(a)(1).

Teeth-related exclusion (§1862(a)(12))Services and appliances in connection with care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth are excluded under §1862(a)(12).