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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)Priority Health TMJ Coverage Update | OpenPayer
    Ask Trek AI about this page
    Currentpriority healthPolicy N/A

    Temporomandibular Joint (TMJ) Disorders Coverage Criteria

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    Defines Priority Health coverage distinctions for medical versus dental services for evaluation and treatment of temporomandibular joint disorders and lists services, coding, and applicability by product type.

    Policy Summary
    Payerpriority health
    PolicyTemporomandibular Joint (TMJ) Disorders Coverage Criteria
    Policy CodePolicy N/A
    Change TypeDeletion — copay specifications removed
    Effective DateJun 1, 2026
    Last ReviewMay 13, 2026
    Next Review DateMay 13, 2026
    Key ActionWhen prior authorization is required, submit documentation demonstrating medical necessity for individual case review.
    SourceLink
    POLICY UPDATE CHANGES

    Deleted copay specifications.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    medical vs dentalpolicy distinguishes covered medical services from non-covered dental services
    lists ~30procedure codes enumerated in coding section
    ICD-10 rangespecific temporomandibular disorder diagnosis codes provided
    HMO/PPO/Medicaid/etcapplies to multiple products

    Coverage Criteria

    Medical Necessity — Covered Services

    Covered when ALL of the following are met

    Medical care coverage: Medical care or services provided to evaluate or treat temporomandibular joint dysfunction or syndrome are a covered medical benefit.
    Physical therapy coverage conditions: Short-term physical therapy is covered when conservative treatment has failed (e.g., change in parafunctional habits, trial of NSAIDs and/or acetaminophen) AND the member has at least two of: (i) symptoms of extra-articular pain related to the muscles of the head and neck region, earaches, headaches, masticatory or cervical myalgia; (ii) pain with chewing; (iii) restricted range of motion.at least 2 findings

    Coverage provided under general physical therapy limitations.

    Examples of covered medical services: Includes medical evaluation; diagnostic work-up (including arthrograms); physical therapy meeting criteria; and surgeries such as arthrocentesis, arthroscopy, condylectomy, arthrotomy, coronoidectomy, and procedures for recurrent dislocation or fracture.

    Not Medically Necessary / Dental Exclusions

    Not covered when ANY of the following dental services are billed as medical benefits

    Examples of non-covered dental services: Dental evaluation or work-up; occlusal adjustments and occlusal therapy; oral appliance therapy (bite block or splint); banding for vertical dimension or malocclusion (orthodontia); surgical correction of malocclusion (orthognathic surgery) unless medically necessary per the Orthognathic Surgery Policy; dental x-rays.

    Dental services are not covered medical benefits.

    Asymptomatic disk/joint findings: Management and treatment of displaced disks or joint sounds in the absence of pain or loss of function is not covered.

    The policy distinguishes between services covered as medical care for temporomandibular joint (TMJ) disorders and services that are considered dental in nature and therefore excluded from the medical benefit. Examples of services that are not covered as medical benefits include: occlusal adjustments and occlusal therapy, oral appliance therapy (bite block or splint), and dental x-rays. These dental interventions should be billed to dental coverage when appropriate and may be denied if submitted as medical claims.

    When planning treatment for TMJ/TMD, follow the criteria for covered medical services (medical evaluation, diagnostic work-up such as arthrograms, short-term physical therapy when criteria are met, and indicated surgical procedures). Dental procedures listed above are excluded from medical coverage and should not be requested or authorized as medical services.

    Management and treatment of displaced disks or joint sounds in the absence of pain or loss of function is considered not medically necessary and is not covered under the medical benefit. Clinical documentation should demonstrate pain or functional impairment if intervention is being requested for internal derangement findings.

    Coding

    Covered CPT/HCPCS CodesCPTCovered
    21010Arthrotomy, temporomandibular joint
    21050Condylectomy, temporomandibular joint (separate procedure)
    21060Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
    21070Coronoidectomy (separate procedure)
    21073Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)
    21085Impression and custom preparation; oral surgical splint
    21110Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
    21116Injection procedure for temporomandibular joint arthrography
    21240Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
    21242Arthroplasty, temporomandibular joint, with allograft
    1–10 of 19
    1/2
    Applicable ICD-10 CodesICD-10
    M26.601 - M26.609Temporomandibular joint disorder, unspecified
    M26.611 - M26.619Adhesions and ankylosis of temporomandibular joint
    M26.621 - M26.629Arthralgia of temporomandibular joint
    M26.631 - M26.639Articular disc disorder of temporomandibular joint
    M26.69Other specified disorders of temporomandibular joint

    Provider Actions & Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization may be required for certain drugs, devices, services and procedures. When prior authorization is required, providers must submit a request that documents medical necessity. Refer to the Priority Health Provider Manual for details and submission instructions.

    • Requests must demonstrate medical necessity
    • See Priority Health Provider Manual for process and contact information
    Note

    Physical Therapy Coverage Prerequisites

    Short-term physical therapy coverage is provided when conservative treatment has failed (e.g., change in parafunctional habits, trial of NSAIDs and/or acetaminophen) and the member has at least two of the following: symptoms of extra-articular pain related to head/neck muscles, pain with chewing, or restricted range of motion.

    • Coverage is for short-term physical therapy only
    • Conservative treatments must have been tried and failed

    Background

    Temporomandibular disease (TMD) is a collective term for clinical problems involving the function of the masticatory muscles and the temporomandibular joint. Presentations can include myofascial pain related to parafunctional habits, referred head and neck pain, earaches, headaches, masticatory or cervical myalgia, pain with chewing, and restricted range of motion. TMJ disorders also encompass internal derangement (such as displaced articular discs), degenerative joint disease, inflammatory arthropathies, and trauma. Because muscle and joint components often overlap, initial evaluation typically includes a medical assessment and diagnostic work-up to determine whether conservative management, physical therapy, or surgical intervention is appropriate.

    Definitions

    Temporomandibular Disease (TMD) — definition and key points
    DefinitionA collective term describing clinical problems involving the function of the masticatory muscles and the temporomandibular (jaw) joint.
    IncludesMasticatory muscle disorders and temporomandibular joint disorders (e.g., internal derangement, degenerative joint disease, rheumatoid arthritis, dislocation, ankylosis, fractures).
    Common causesParafunctional habits such as bruxism and clenching, referred pain from the cervical spine, systemic muscle disorders (e.g., dyskinesia, fibromyalgia, myositis).
    Clinical presentationSymptoms often overlap between muscle and joint components; initial presentation may include pain of the head, neck and jaw with possible coexistence of both elements.
    Terminology noteAlso referred to as 'TMJ syndrome' in clinical practice, which has contributed to diagnostic and treatment confusion.
    Policy Summary
    Payerpriority health
    PolicyTemporomandibular Joint (TMJ) Disorders Coverage Criteria
    Policy CodePolicy N/A
    Change TypeDeletion — copay specifications removed
    Effective DateJun 1, 2026
    Last ReviewMay 13, 2026
    Next Review DateMay 13, 2026
    Key ActionWhen prior authorization is required, submit documentation demonstrating medical necessity for individual case review.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & RequirementsBackgroundDefinitions
    Documentation Required

    Prior Authorization and Documentation

    When prior authorization is required, providers must submit documentation demonstrating medical necessity. Individual case review may allow coverage for investigational yet promising treatments; such requests require prior plan approval and will be reviewed by a Priority Health medical director or clinical pharmacist.

    • Documentation should support medical necessity and clinical rationale
    • Individual case review possible for experimental/investigational treatments with prior plan approval
    Denial Risk

    Non-covered Dental Services May Be Denied

    Dental-classified services billed as medical benefits may be denied. Examples of dental services that are not covered include: dental evaluation/work-up, occlusal adjustments/therapy, oral appliance therapy (bite block or splint), banding for vertical dimension or malocclusion (orthodontia), and dental x-rays. Orthognathic surgery may be covered only if medically necessary per separate policy.

    • Not covered examples: dental evaluation, occlusal adjustments, oral appliance therapy, banding for malocclusion, dental x-rays
    • Orthognathic surgery coverage requires separate medical necessity determination