CurrentCareSource GeorgiaPolicy MP-MM-1418

Temporomandibular Disorders - Nonsurgical Treatment

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This policy governs medical necessity, documentation, diagnostic evaluation, and nonsurgical treatment of temporomandibular disorders, including services provided by dentists within the scope of their state license. It applies to CareSource Marketplace plans in Georgia, Ohio, and West Virginia.

Policy Summary

PayerCareSource Georgia

PolicyTemporomandibular Disorders - Nonsurgical Treatment

Policy CodePolicy MP-MM-1418

Change TypeAdministrative and reference updatesno material clinical or coverage change

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionSubmit comprehensive clinical office notes documenting the abnormality, functional impairment, prior treatment, and treatment plan for TMD services.

SourceLink

POLICY UPDATE CHANGES

The policy title was amended by replacing TMJD/TMJ terminology with TMD terminology.

References to surgical procedures were removed from the policy during the 2025 revision.

The policy received updated references and minor edits to the Section IV exclusions in the 2026 revision.

2+Minimum qualifying clinical symptoms or signs

<35 mmInterincisal opening threshold

<35 mm

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CurrentCareSource GeorgiaPolicy MP-MM-1418

Temporomandibular Disorders - Nonsurgical Treatment

Customize your policy alerts

Sign up for CareSource Georgia Policy MP-MM-1418 alerts

Get alerted when Policy MP-MM-1418 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerCareSource Georgia

PolicyTemporomandibular Disorders - Nonsurgical Treatment

Policy CodePolicy MP-MM-1418

Change TypeAdministrative and reference updatesno material clinical or coverage change

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionSubmit comprehensive clinical office notes documenting the abnormality, functional impairment, prior treatment, and treatment plan for TMD services.

SourceLink

POLICY UPDATE CHANGES

The policy title was amended by replacing TMJD/TMJ terminology with TMD terminology.

References to surgical procedures were removed from the policy during the 2025 revision.

The policy received updated references and minor edits to the Section IV exclusions in the 2026 revision.

2+Minimum qualifying clinical symptoms or signs

<35 mmInterincisal opening threshold

<35 mm

Lateral excursive movement threshold

<4 mmProtrusive excursive movement threshold

>5 mmDeviation on opening threshold

8Experimental and investigational exclusion categories

Medical Necessity and Coverage Criteria

Clinical information and documentation requirements

Covered when ALL documentation criteria are met.

Required clinical documentation

Office note elements
- Abnormality and impairment: A well-defined physical and/or physiological abnormality, such as a congenital abnormality or functional or skeletal impairment, resulting in a medical condition that has required or will require TMD treatment; the resulting functional deficit or impairment; the recurrent or persistent nature of that deficit; and the degree to which the abnormality is causing impairment.
- Prior treatment: Prior medical and surgical treatment must be documented.
Diagnostic support: Applicable TMD radiological films and/or reports must be included, such as AP radiographs, panoramic radiographs, CT scans, MRI, or CBCT x-rays. Blood tests and laboratory results must be included when systemic illness is suspected, and psychological evaluation results must be included when applicable.AS APPLICABLE
Treatment plan: The treating clinician's plan of care must include treatment objectives and the expected outcome for improvement of the functional deficit.

Diagnostic procedures

The following diagnostic modalities are considered medically necessary when clinically indicated.

Examination: Physical examination, including psychological evaluation when applicable.
Radiologic examination using contrast studies may be performed; standard dental radiographic images are excluded.
TMJ ultrasound: Temporomandibular joint ultrasound may be performed.
CT or MRI may be performed for a presurgical examination, subject to prior authorization review by CareSource's imaging management vendor and the vendor's review criteria.
Laboratory evaluation: Laboratory studies and blood tests may be performed when systemic illness is suspected to be the cause of the TMD, subject to applicable prior authorization review by CareSource's laboratory vendor and vendor review criteria.

Nonsurgical treatment medical necessity

Appliance therapy, such as an occlusal orthotic device, physical therapy, masticatory muscle and temporomandibular joint injections, and trigger point injections are medically necessary when ALL of the following conditions are met.

Nonsurgical treatment criteria

Significant clinical symptoms and signs
- Extra-articular pain: Pain related to muscles of the head and neck region, such as earaches, headaches, masticatory myalgias, or cervical myalgias.
- Painful chewing not related to dental pathology.
- Restricted range of motion
  - Interincisal opening is less than 35 mm.<35 mm

Standard dental radiographic procedures are considered experimental and investigational for TMD diagnosis and nonsurgical treatment because of insufficient evidence of efficacy; therefore, they are not a covered benefit.

Hydrotherapy, including immersion therapy and whirlpool baths, is considered experimental and investigational and is not covered.

Iontophoresis is considered experimental and investigational and is not covered.

Orthodontic or bite adjustment services are considered experimental and investigational and are not covered.

Biofeedback is considered experimental and investigational and is not covered.

Occlusal analysis is considered experimental and investigational and is not covered.

Irreversible procedures are considered experimental and investigational and are not covered. These include orthodontics, occlusal adjustment, crowns, onlays, fixed or removable partial dentures, and full dentures.

Jaw motion rehabilitation systems are considered experimental and investigational and are not covered.

Coding and Clinical Thresholds

MCG clinical guideline reference codesmixed

A-0492	Temporomandibular Joint Arthroscopy
A-0521	Temporomandibular Joint Modified Condylotomy
A-0522	Temporomandibular Joint Arthrotomy
A-0523	Temporomandibular Joint Arthroplasty

Interincisal opening

ThresholdLess than 35 mm

MeasurementGreatest distance between the front upper and lower teeth when the mouth is wide open

Clinical roleOne restricted-motion finding that may qualify as a significant TMD symptom or sign

Lateral excursive movement

ThresholdLess than 35 mm

Movement measuredSide-to-side movement of the jaw

Clinical role

Authorization and Documentation Requirements

Prior Authorization

CT/MRI Vendor Review

A presurgical CT or MRI requires prior authorization review by CareSource's imaging management vendor and is subject to the vendor's review criteria.

Prior Authorization

Laboratory Vendor Review

Laboratory studies and blood tests performed when systemic illness is suspected may require prior authorization review by CareSource's laboratory vendor and are subject to vendor review criteria.

Prior Authorization

Treatment Medical Necessity Review

The Plan's prior authorization process determines whether requested nonsurgical TMD treatment is medically necessary for the specific indication and related medical condition.

Temporomandibular Disorders Overview

Temporomandibular disorders (TMD) involve the masticatory muscles, the temporomandibular joints, or both. They may include articular disorders and masticatory muscle disorders. Diagnosis is primarily based on clinical examination and patient-reported symptoms, with imaging or laboratory testing used when needed to identify pathology, establish prognosis, or investigate suspected systemic illness. Most patients improve with noninvasive measures such as education, self-care, behavioral therapy, medication, physical therapy, and occlusal devices; referral to an oral and maxillofacial surgeon may be appropriate when symptoms persist.

Key Terms

Arthrography

TypeImaging procedure

Diagnostic useUsed to evaluate and diagnose unexplained pain and joint conditions

TMD indicationMay be considered when trauma or suspected pathology is present and the involved structures cannot be confirmed by standard imaging

Articular disorder

CategoryTemporomandibular joint disorder

Included conditionsAnkylosis; congenital or developmental disorders; disc derangement disorders; and fractures

Additional conditions

Policy Summary

PayerCareSource Georgia

PolicyTemporomandibular Disorders - Nonsurgical Treatment

Policy CodePolicy MP-MM-1418

Change TypeAdministrative and reference updatesno material clinical or coverage change

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionSubmit comprehensive clinical office notes documenting the abnormality, functional impairment, prior treatment, and treatment plan for TMD services.

SourceLink

On This Page

Joint arthrography

Trauma or suspected pathology: Patient history and physical examination findings indicate joint trauma and/or suspected pathology.
Structures involved: Confirmation of the suspected structures involved is needed.
Insufficient standard imaging: Confirmation cannot be made from standard imaging.

Lateral excursive movement is less than 35 mm.<35 mm

Protrusive excursive movement is less than 4 mm.<4 mm

Deviation on opening is greater than 5 mm.>5 mm

Failure of conservative treatment: Symptoms have not resolved after removal of precipitating activities, such as gum chewing or eating hard candies; pharmacologic treatment, such as anti-inflammatory or analgesic medications; or a change in diet texture.

One restricted-motion finding that may qualify as a significant TMD symptom or sign

Protrusive excursive movement

ThresholdLess than 4 mm

Movement measuredFront-to-back motion of the jaw

Clinical roleOne restricted-motion finding that may qualify as a significant TMD symptom or sign

Deviation on opening

ThresholdGreater than 5 mm

Finding assessedDeviation of the jaw when opening

Clinical roleOne restricted-motion finding that may qualify as a significant TMD symptom or sign

Qualifying clinical symptoms and signs

Minimum requiredAt least 2 qualifying clinical symptoms or signs

Qualifying findingExtra-articular pain related to muscles of the head and neck region, such as earaches, headaches, masticatory myalgias, or cervical myalgias

Qualifying findingPainful chewing not related to dental pathology, or a restricted range-of-motion finding

Step Therapy

Conservative Treatment Must Be Unsuccessful

Covered nonsurgical TMD treatment requires qualifying symptoms that remain unresolved after conservative treatment.

Conservative treatment may include removal of precipitating activities, pharmacological treatment such as anti-inflammatory or analgesic medications, and a change in diet texture.

Documentation Required

Comprehensive Clinical Office Notes

Submit comprehensive clinical office notes documenting the well-defined physical and/or physiological abnormality requiring or expected to require TMD treatment and its functional impact.

Document the resulting functional deficit or impairment and whether it is recurrent or persistent.
Describe the degree of impairment and prior medical and surgical treatment.

Documentation Required

TMD Imaging Documentation

Include applicable TMD radiological films and/or reports supporting the diagnosis and requested treatment.

Examples include AP radiographs, panoramic radiographs, CT scans, MRI, and CBCT X-rays.

Documentation Required

Laboratory Documentation When Indicated

When systemic illness is suspected as the cause of the temporomandibular disorder, include completion and results of the applicable blood tests and laboratory studies.

Documentation Required

Psychological Evaluation When Indicated

When applicable, include completion and results of a psychological evaluation.

Documentation Required

Plan of Care and Expected Outcome

Include the treating clinician's plan of care for improving the functional deficit.

State the treatment objectives and expected outcome.

Denial Risk

Incomplete Medical Necessity Documentation

Treatment may be denied when required medical-necessity documentation or a well-defined physical and/or physiological abnormality is absent.

Documentation must establish the associated functional deficit or impairment, its recurrent or persistent nature, degree of impairment, and prior medical and surgical treatment.

Denial Risk

Insufficient Clinical Symptoms or Failed Conservative Care

Treatment may be denied when qualifying clinical findings or unsuccessful conservative care are not established.

Nonsurgical treatment requires significant clinical symptoms and signs, including at least two qualifying findings such as extra-articular head or neck pain, non-dental painful chewing, or restricted range of motion.
Restricted range of motion may include interincisal opening less than 35 mm, lateral excursive movement less than 35 mm, protrusive excursive movement less than 4 mm, or deviation on opening greater than 5 mm.

Denial Risk

Excluded Experimental or Investigational Services

The following are considered experimental and investigational for diagnosis or nonsurgical TMD treatment due to insufficient evidence of efficacy and are not covered benefits; the list is not all-inclusive.

Standard dental radiographic procedures
Hydrotherapy, including immersion therapy and whirlpool baths
Iontophoresis
Orthodontic or bite-adjustment services
Biofeedback
Occlusal analysis
Any irreversible procedure, including orthodontics, occlusal adjustment, crowns, onlays, fixed or removable partial dentures, or full dentures
Jaw motion rehabilitation systems

Inflammatory disorders, osteoarthritis, and joint dislocation

Bruxism

DefinitionClenching or grinding of the teeth

ActionClenching the teeth

ActionGrinding the teeth

Masticatory muscle disorder

CategoryTemporomandibular joint disorder involving the masticatory muscles

Included conditionMyofascial pain or myofibrotic contracture

Additional conditionsMyospasm or neoplasia

Physical therapy

DefinitionTherapy used in the treatment of temporomandibular disorders

Exercises and manual therapyRepetitive active or passive jaw exercises, joint manipulation, and stretch technique

Other modalitiesThermal modalities using hot or cold packs, vapor coolant spray, and electro-galvanic stimulation

Temporomandibular joint (TMJ)

Anatomical structureConnecting hinge mechanism

Upper connectionThe temporal bone at the base of the skull

Lower connectionThe mandible, or lower jaw

Tinnitus

DefinitionRinging or other noises

LocationMay occur in one ear

LocationMay occur in both ears

Trismus

DefinitionLocking of the jaw

CauseMuscle spasms

Affected functionJaw movement may become locked or restricted