CurrentHealth Choice ArizonaPolicy N/A

Temporomandibular Joint Disorder

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This policy governs coverage determinations for diagnostic procedures and nonsurgical and surgical treatments for temporomandibular joint disorder (TMJD), subject to the member’s benefit plan and the policy’s medical-necessity or experimental/investigational criteria.

Policy Summary

PayerHealth Choice Arizona

PolicyTemporomandibular Joint Disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 9, 2023

Last ReviewJan 9, 2023

Next Review DateJan 1, 2024

Key ActionDocument objective evidence of internal derangement or degenerative joint disease and failure of conservative treatment for arthroscopic surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Medically necessary diagnostic categories

2Medically necessary nonsurgical treatment categories

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CurrentHealth Choice ArizonaPolicy N/A

Temporomandibular Joint Disorder

Customize your policy alerts

Sign up for all health_choice_arizona policy alerts

Know when health_choice_arizona releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerHealth Choice Arizona

PolicyTemporomandibular Joint Disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 9, 2023

Last ReviewJan 9, 2023

Next Review DateJan 1, 2024

Key ActionDocument objective evidence of internal derangement or degenerative joint disease and failure of conservative treatment for arthroscopic surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Medically necessary diagnostic categories

2Medically necessary nonsurgical treatment categories

Medically necessary surgical treatment categories

5Investigational criteria for diagnostic and nonsurgical services

41Procedure and supply codes

TMJD Coverage Criteria

Medically Necessary Diagnostic Procedures

The following diagnostic procedures used in the diagnosis of temporomandibular joint disorder (TMJD) are considered medically necessary:

ONE or more of the following

Cephalograms (x-rays of the jaws and skull)
Computed tomography (CT) scan or magnetic resonance imaging (MRI)
Diagnostic x-rays, tomograms, and arthrograms
Pantograms (x-ray of the maxilla and mandible)

Experimental or Investigational Diagnostic Procedures

Diagnostic procedures used in the diagnosis of TMJD are considered experimental or investigational when ANY ONE or more of the following criteria are met. These procedures include, but are not limited to, the examples listed below.

ANY ONE or more of the following criteria

Lack of final approval from the appropriate governmental regulatory bodies (e.g., Food and Drug Administration)
Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes
Insufficient evidence to support improvement of the net health outcome
Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives
Insufficient evidence to support improvement outside the investigational setting

Examples include: arthroscopy of the temporomandibular joint (TMJ) for purely diagnostic purposes; computerized mandibular scan; electromyography (EMG), including surface EMG; joint vibration analysis; kinesiography; muscle testing; neuromuscular junction testing; range-of-motion measurements; somatosensory testing; standard dental radiographic procedures; thermography; transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing; and ultrasound imaging/sonogram.

Medically Necessary Nonsurgical Treatments

The following nonsurgical treatments for the treatment of TMJD are considered medically necessary:

ONE or more of the following

Intraoral removable prosthetic devices or appliances, encompassing fabrication, insertion, and adjustment
Pharmacologic treatment, such as anti-inflammatory, muscle-relaxing, and analgesic medications

Experimental or Investigational Nonsurgical Treatments

Nonsurgical treatments for the treatment of TMJD are considered experimental or investigational when ANY ONE or more of the following criteria are met. These treatments include, but are not limited to, the examples listed below.

ANY ONE or more of the following criteria

Lack of final approval from the appropriate governmental regulatory bodies (e.g., Food and Drug Administration)
Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes
Insufficient evidence to support improvement of the net health outcome
Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives
Insufficient evidence to support improvement outside the investigational setting

Medically Necessary Surgical Treatments

The following surgical treatments for the treatment of TMJD are considered medically necessary:

ONE or more of the following

Arthrocentesis
Arthroscopic surgery in individuals with objectively demonstrated internal derangements (displaced discs) or degenerative joint disease, demonstrated by physical examination or imaging, who have failed conservative treatment
Manipulation for reduction of fracture or dislocation of the TMJ
Open surgical procedures when TMJD results from congenital anomalies, trauma, or disease in individuals who have failed conservative treatment. These procedures include, but are not limited to, arthroplasties, condylectomies, disc removal, and meniscus or disc plication.

Procedure and Supply Codes

CPTmixed

20605
20606
21010
21116
21050
21060
21073
21240
21241
21242

1–10 of 41

1/5

Documentation and Treatment Requirements

Step Therapy

Conservative Treatment Before Surgery

Providers should document an initial trial of conservative therapy before proceeding to invasive or permanent TMJD treatment, including surgery. Conservative measures may include soft foods, rest, heat or ice, avoiding extreme jaw movements, and anti-inflammatory medication.

Initial conservative therapy is generally expected before more invasive or permanent treatment.
Document the conservative measures attempted, duration, response, and reason for escalation.

Documentation Required

Objective Evidence Required for Arthroscopic Surgery

Arthroscopic surgery is medically necessary only when the patient has an objectively demonstrated internal derangement (displaced disc) or degenerative joint disease, established by physical examination or imaging, and has failed conservative treatment.

Objective evidence must be documented through physical examination or imaging.

Clinical Background

Temporomandibular joint disorder (TMJD) is a group of disorders involving pain in the temporomandibular joint and surrounding tissues. Symptoms may include jaw clicking, headaches, jaw closing or locking from muscle spasms (trismus) or a displaced disc, referred pain in the ears, neck, arms, or spine, tinnitus, and bruxism (clenching or grinding of the teeth). Symptoms are often short-term and self-limiting; conservative measures such as soft foods, rest, heat or ice, avoiding extreme jaw movements, and anti-inflammatory medication are generally recommended before more invasive or permanent treatment.

Policy Definitions

Temporomandibular joint disorder (TMJD)

ConditionA group of disorders characterized by pain in the temporomandibular joint and surrounding tissues.

Primary siteTemporomandibular joint.

Associated tissuesSurrounding tissues may also be affected.

Experimental or investigational

ExperimentalThe term is used in this policy.

InvestigationalThe term is used in this policy.

Policy meaningFor purposes of this policy, experimental and investigational are interchangeable terms.

Policy Summary

PayerHealth Choice Arizona

PolicyTemporomandibular Joint Disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 9, 2023

Last ReviewJan 9, 2023

Next Review DateJan 1, 2024

Key ActionDocument objective evidence of internal derangement or degenerative joint disease and failure of conservative treatment for arthroscopic surgery.

SourceLink

On This Page

Examples include: acupuncture; biofeedback; dental restorations or prostheses; devices promoted to maintain joint range of motion and to develop muscles involved in jaw function; dextrose prolotherapy; electrogalvanic stimulation; hyaluronic acid; iontophoresis; orthodontic services; percutaneous electrical nerve stimulation; platelet concentrates; transcutaneous electrical nerve stimulation; and ultrasound.

Document failure of conservative treatment before requesting arthroscopic surgery.

Documentation Required

Exception Requests Require Complete Rationale

When requesting an exception to these guidelines, providers must submit complete medical rationale and supporting clinical documentation to BCBSAZ. Coverage remains subject to the member’s benefit plan and applicable mandates.

Include the diagnosis, requested service, clinical history, prior treatment, treatment response or failure, and the specific reason the guideline exception is medically appropriate.
Submit relevant examination findings, imaging, test results, and other records supporting the exception request.

Denial Risk

Diagnostic Procedures: Investigational Criteria

Diagnostic procedures for TMJD are considered experimental or investigational when any ONE or more of the listed criteria applies, creating a denial risk for procedures that do not meet applicable evidence and regulatory standards.

Lack of final approval from the appropriate governmental regulatory body, such as the FDA.
Insufficient scientific evidence to permit conclusions about health outcomes.
Insufficient evidence of improvement in the net health outcome.
Insufficient evidence that the procedure improves the net health outcome as much as or more than established alternatives.
Insufficient evidence of improvement outside the investigational setting.
Examples include diagnostic TMJ arthroscopy, computerized mandibular scan, EMG, joint vibration analysis, kinesiography, muscle testing, neuromuscular junction testing, range-of-motion measurements, somatosensory testing, standard dental radiographs, thermography, transcranial or lateral skull x-rays, intraoral or gnathic arch tracing, and ultrasound imaging or sonogram.

Denial Risk

Nonsurgical Treatments: Investigational Criteria

The listed nonsurgical TMJD treatments are considered experimental or investigational when any ONE or more of the following criteria applies. Verify the treatment’s regulatory status and evidence before requesting coverage.

Lack of final approval from the appropriate governmental regulatory body, such as the FDA.
Insufficient scientific evidence to permit conclusions about health outcomes.
Insufficient evidence of improvement in the net health outcome.
Insufficient evidence that the treatment improves the net health outcome as much as or more than established alternatives.
Insufficient evidence of improvement outside the investigational setting.
Examples include acupuncture, biofeedback, dental restorations or prostheses, jaw-range-of-motion or muscle-development devices, dextrose prolotherapy, electrogalvanic stimulation, hyaluronic acid, iontophoresis, orthodontic services, percutaneous electrical nerve stimulation, platelet concentrates, transcutaneous electrical nerve stimulation, and ultrasound.

Documentation Required

Surgical Eligibility Requirements

For surgical treatment, document the applicable diagnosis, objective findings, prior conservative treatment and outcome, and the indication supporting the requested procedure. Arthrocentesis and manipulation for reduction of TMJ fracture or dislocation are identified as medically necessary; open surgery is medically necessary for TMJD resulting from congenital anomaly, trauma, or disease when conservative treatment has failed.

Arthroscopic surgery requires objectively demonstrated internal derangement (displaced disc) or degenerative joint disease by physical examination or imaging, plus failure of conservative treatment.
Open surgical procedures require TMJD caused by congenital anomaly, trauma, or disease, plus failure of conservative treatment; examples include arthroplasty, condylectomy, disc removal, and meniscus or disc plication.
Include the operative indication, examination and/or imaging findings, conservative-treatment history and failure, and relevant records with the request.