CurrentColorado Rocky Mountain Health PlansPolicy MMP025.12

Treatment of Temporomandibular Joint (TMJ)

Medicare Advantage medical policy governing coverage considerations for a variety of treatments for temporomandibular joint disorders, including medications, injections, devices, and surgeries, as applied to UnitedHealthcare Medicare Advantage members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTreatment of Temporomandibular Joint (TMJ)

Policy CodePolicy MMP025.12

Change TypeRoutine review; no change

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument the specific condition or symptom treated (a TMJ diagnosis alone is insufficient) when submitting claims and retain supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines

2026-02-01effective date

Medicare Advantageapplicability

manylisted CPT/HCPCS codes

Routine reviewrecent revision note

Coverage Criteria

General Coverage Determination

Covered when the conditions below and applicable Medicare guidance or referenced UnitedHealthcare policies are met:

Medicare exclusions and local policies: Many TMJ procedures fall within Medicare statutory exclusions for items and services that have not been demonstrated to be reasonable and necessary (§1862(a)(1)) or for services in connection with dental care/structures supporting teeth (§1862(a)(12)); a diagnosis of TMJ alone is insufficient — the specific underlying condition or symptom must be documented.

Refer to Medicare Benefit Policy Manual, Chapter 15 §150.1 - Treatment of Temporomandibular Joint Syndrome

Coverage when Medicare NCD/LCD exists: When an applicable Medicare NCD or LCD/LCA provides coverage criteria for a specific therapy (e.g., certain botulinum toxin LCDs), those Medicare criteria must be followed and compliance is required where applicable.

See specific LCDs/LCAs referenced for Botulinum Toxins A and B

Coverage when Medicare guidance is absent: Where Medicare does not have an NCD and no LCD/LCA exists, UnitedHealthcare applies internal coverage criteria and referenced UnitedHealthcare Commercial Medical Policies for that treatment modality (examples: corticosteroid injections, physical therapy, arthroscopy, arthroplasty, sodium hyaluronate injections, orthognathic surgery).

Refer to corresponding UnitedHealthcare Commercial Medical Policy named for each treatment

General coverage approach

UnitedHealthcare alignment with Medicare and approach when Medicare guidance is absent or flexible:

Medicare alignment: UnitedHealthcare follows Medicare statutes, regulations, NCDs, LCDs, and manuals when determining coverage for Medicare Advantage members; where there is a conflict, Medicare source materials apply.

Medicare source materials include NCDs, LCDs, and CMS manuals

Internal criteria application: If Medicare guidance is absent or allows flexibility, UnitedHealthcare applies internal coverage criteria developed from clinical evidence and widely used treatment guidelines to determine whether an item or service may be reasonable and necessary.

Internal criteria are used only where Medicare guidance is lacking or explicitly allows broader coverage

Policy currency and scope: Medicare Advantage Policies are regularly reviewed and may be updated; they are intended to support UnitedHealthcare coverage decisions but do not replace Medicare source materials.

UnitedHealthcare may modify these policies at any time by publishing a new version

Application of dental or orthodontic devices and appliances is not covered when billed for dental care or structures directly supporting teeth. This exclusion applies whether or not the device or appliance is provided in conjunction with oral or orthognathic surgery, except when such devices are used specifically for treatment of Temporomandibular Joint (TMJ) disorders as described in the Medicare Benefit Policy Manual, Chapter 15, §150.1.

Benefit coverage is determined by the member specific benefit plan document and applicable laws. If there is any conflict between this policy and the member's benefit plan, the member specific benefit plan document supersedes this policy. For plan‑specific coverage questions, providers should consult the member's benefit plan or contact customer service using the number on the member ID card.

Services that have not been demonstrated to be reasonable and necessary for diagnosis or treatment are excluded under §1862(a)(1) of the Social Security Act. In addition, services in connection with dental care or structures directly supporting teeth are excluded under §1862(a)(12). A claim listing a diagnosis of TMJ alone is insufficient to establish medical necessity; the specific underlying condition or symptom must be documented and justified.

This policy is provided for informational purposes and is not a substitute for individualized medical judgment. It is intended as a general reference to support coverage decisions; physicians and treating providers retain responsibility for clinical decision‑making. Providers are expected to retain or have access to supporting documentation and to exercise independent clinical discretion when determining appropriate care.

Applicable Codes & Coding Guidance

Treatments Such as the Injection of Corticosteroid, Physical Therapy, Arthroscopy, or Arthroplasty / Orthognathic SurgeryCPT

21240	Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242	Arthroplasty, temporomandibular joint, with allograft
21247	Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts)
97039	Unlisted modality (specify type and time if constant attendance)
97139	Unlisted therapeutic procedure (specify)
21141	Reconstruction midface, LeFort I; single piece, segment movement in any direction, without bone graft
21142	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft
21143	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft
21145	Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
21146	Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

Orthognathic Surgery CPT Codes (continued)CPT

21147	Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
21150	Reconstruction midface, LeFort II; anterior intrusion
21151	Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)
21154	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I
21155	Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I
21159	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement, requiring bone grafts (includes obtaining autografts); without LeFort I
21160	Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement, requiring bone grafts (includes obtaining autografts); with LeFort I
21188	Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
21193	Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
21194	Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone grafts (includes obtaining graft)

Orthognathic and Mandibular Reconstruction CPT CodesCPT

21195	Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196	Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
21198	Osteotomy, mandible, segmental
21199	Osteotomy, mandible, segmental; with genioglossus advancement
21206	Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21215	Graft, bone; mandible (includes obtaining graft)
21244	Reconstruction of mandible, extraoral, with transosteal bone plate
21245	Reconstruction of mandible or maxilla, subperiosteal implant; partial
21246	Reconstruction of mandible or maxilla, subperiosteal implant; complete

Botulinum Toxins A and BHCPCS

J0585	Injection, onabotulinumtoxinA, 1 unit
J0586	Injection, abobotulinumtoxinA, 5 units
J0587	Injection, rimabotulinumtoxinB, 100 units
J0588	Injection, incobotulinumtoxinA, 1 unit
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit

Sodium Hyaluronate InjectionsHCPCS

J7320	Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg
J7321	Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose
J7322	Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
J7323	Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
J7324	Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7326	Hylauronan or derivative, Gel-One, for intra-articular injection, per dose
J7327	Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose
J7329	Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg
J7331	Hyaluronan or derivative, Synojoynt, for intra-articular injection, 1 mg
J7332	Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg

Referenced coding systemsmixed

No codes listed

Applicable Codes Notice

Scope of code listThe listed procedure and diagnosis codes are provided for reference only and may not be all inclusive.

No coverage implicationListing of a code in this policy does not imply the service is a covered or non‑covered health service.

Benefit determinationBenefit coverage is determined by the member specific benefit plan document and applicable laws.

No reimbursement guaranteeInclusion of a code does not imply any right to reimbursement or guarantee of claim payment.

Other policies may applyOther Policies and Guidelines may apply to the services described by listed codes.

Coding metadata

Coding definitions usedPolicy uses CPT, CMS, and other coding guidelines for definitional purposes only.

Provider responsibilityProviders are responsible for submission of accurate claims using applicable coding guidelines.

Delegate requirementsFor Medicare Advantage members where a delegate manages utilization management/prior authorization, the delegate's requirements must be followed.

Reference purposeReferences to CPT or other sources are for definitional purposes and do not guarantee reimbursement.

Provider Actions and Requirements

Prior Authorization

Delegate Prior Authorization Requirement

Prior authorization requirements may apply. For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management and prior authorization requirements, providers must follow the delegate's prior authorization processes and submit any required documentation to the delegate as instructed.

Follow delegate-managed prior authorization procedures when applicable
Submit documentation to the delegate per their requirements

Note

Part D Medication Coverage

Oral medications used for TMJ symptoms may be covered under the member's Part D prescription drug benefit rather than under medical benefits. Providers should contact the Prescription Solutions (UnitedHealthcare Part D) customer service to determine Part D coverage eligibility and billing direction before submitting claims under medical benefits.

Check Part D coverage for oral medications with Prescription Solutions
Do not assume medical coverage—confirm billing responsibility prior to claim submission

Documentation Required

Documentation, Claims Accuracy, and Excluded Services

Providers are responsible for accurate claims and for retaining or having access to supporting documentation when requested. A diagnosis code of TMJ alone is insufficient; claims must specify the condition or symptom being treated. Appliances and dental/orthodontic devices are generally excluded unless specifically covered for TMJ. Follow coding and billing guidelines and maintain documentation to support medical necessity and coverage determinations.

Ensure claims identify the specific condition or symptom treated (TMJ diagnosis alone is insufficient)
Retain documentation and provide upon request to support coverage and medical necessity
Appliances/dental devices are typically excluded unless explicitly covered for TMJ

Background

Temporomandibular joint (TMJ) conditions encompass a wide range of clinical problems and treatment approaches. Many procedures used to manage TMJ may fall within Medicare statutory exclusions — either because they have not been shown to be reasonable and necessary for diagnosis or treatment (§1862(a)(1)) or because they relate to dental care or structures directly supporting teeth (§1862(a)(12)). As a result, a diagnosis of TMJ on its own is insufficient for coverage; the specific condition or symptom and the medical justification for the chosen treatment must be documented. Refer to the Medicare Benefit Policy Manual, Chapter 15, §150.1 for guidance on treatment of TMJ syndrome.

Definitions

TMJ diagnosis on claim

Insufficient claim diagnosisA diagnosis of TMJ on a claim is insufficient by itself to support coverage; the actual condition or symptom must be determined and documented.

Medicare exclusionsMany TMJ procedures may fall within Medicare statutory exclusions under §1862(a)(1) (not reasonable and necessary) and §1862(a)(12) (services in connection with dental care).

Reference guidanceRefer to Medicare Benefit Policy Manual, Chapter 15, §150.1 - Treatment of Temporomandibular Joint Syndrome for additional direction.

Medicare source materials

Included Medicare materialsMedicare source materials may include CMS statutes, regulations, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and manuals.

Primary authorityWhere there is a conflict between this policy and Medicare source materials, the Medicare source materials apply.

Policy development useUnitedHealthcare uses Medicare source materials among other resources to develop Medicare Advantage Policies.

Not a replacementThis policy is not a replacement for the Medicare source materials that outline Medicare coverage requirements.