Treatment of Temporomandibular Joint (TMJ)
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Medicare Advantage medical policy governing coverage considerations for diagnosis and treatment options for temporomandibular joint (TMJ) conditions, including medications, injections, devices, and surgical procedures for UnitedHealthcare Medicare Advantage members.
Coverage Rationale Treatments Such as the Injection of Corticosteroid and Physical Therapy • Modified content heading; previously named Treatments Such as the Injection of Corticosteroid, Physical Therapy, or Arthroplasty
Replaced language indicating 'Medicare does not have a National Coverage Determination (NCD) for corticosteroid injections, physical therapy, or arthroscopy used for the treatment of Treatment of Temporomandibular Joint Syndrome (TMJ)' with 'Medicare does not have an NCD for corticosteroid injections and physical therapy used for the treatment of TMJ'
Applicable Codes Removed CPT code 21247
Supporting Information Archived previous policy version MMP025.13
Coverage Criteria
Coverage Rationale / Examples
Covered when ALL of the following are met:
Claims must document the specific underlying condition or symptom (a claim diagnosis of 'TMJ' alone is insufficient)
Refer to the Botulinum Toxin Types A and B LCD/LCA table for specific local coverage requirements
See Coverage Rationale and related UnitedHealthcare policies for specifics
Prior authorization or referral to the DME Grid may be required
Providers are responsible for retaining and providing documentation on request; failure to provide may risk claim denial
Application when Medicare coverage documents are absent
UnitedHealthcare follows Medicare guidance; when no applicable Medicare coverage document exists, internal policy criteria apply:
Internal criteria were developed from evaluation of clinical evidence and widely used guidelines; Medicare source materials take precedence where they exist
Items and services that are provided in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered under this policy. This exclusion is consistent with the Medicare Benefit Policy Manual, Chapter 15, § 150 (Dental Services), and applies whether the service is performed alone or in conjunction with other oral procedures.
Application of dental or orthodontic devices and appliances is generally not covered, except when used for the treatment of Temporomandibular Joint (TMJ) disorders as noted in the Medicare Benefit Policy Manual, Chapter 15, § 150.1. Where Medicare statutes, NCDs, LCDs, or LCAs specifically address a device or appliance, those Medicare source materials take precedence; when such Medicare guidance is absent or allows flexibility, UnitedHealthcare internal criteria as described in this policy apply.
This policy removes CPT code 21247 from the list of applicable codes. Providers should consult the member-specific benefit documents and applicable plan exclusions to determine whether a particular service remains excluded for a specific member or plan.
Services that have not been demonstrated to be reasonable and necessary under §1862(a)(1) of the Social Security Act are not payable. A claim listing a diagnosis of 'TMJ' alone is insufficient to establish medical necessity; the actual underlying condition or symptom must be identified and documented to support that the service is reasonable and necessary under Medicare standards.
Where there is no applicable Medicare NCD, LCD, or LCA, or where Medicare guidance includes explicit flexibility, UnitedHealthcare applies its internal coverage criteria as described in this Medical Policy. Those internal criteria were developed from a review of relevant clinical evidence and guidelines and are used to determine whether an item or service might be reasonable and necessary in the absence of definitive Medicare coverage guidance.
Coding
| 97039 | Unlisted modality (specify type and time if constant attendance) |
| 97139 | Unlisted therapeutic procedure (specify) |
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) |
| 21242 | Arthroplasty, temporomandibular joint, with allograft |
| 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) |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion |
| 21247 | CPT code (removed from applicable codes) |
| L33428 | LCD: Cosmetic and Reconstructive Surgery |
| A56658 | LCA: Billing and Coding: Cosmetic and Reconstructive Surgery |
| L39857 | LCD: Botulinum Toxin Types A and B for the Treatment of TMJ |
| A59726 | LCA: Reconstructive Surgery Billing and Coding |
| L35170 | LCD: Botulinum Toxin Types A and B Policy |
| A57185 | LCA: Billing and Coding: Botulinum Toxin Types A and B Policy |
| L35172 | LCD: Botulinum Toxin Types A and B |
| A57186 | LCA: Billing and Coding: Botulinum Toxin Types A and B |
| L39836 | LCD: Botulinum Toxin Injections |
| A59714 | LCA: Billing and Coding: Botulinum Toxin Injections |
Provider Actions & Prior Authorization
Prior authorization required for jaw motion rehab/traction devices
Prior authorization or referral to the Durable Medical Equipment policy is required for jaw motion rehabilitation systems (HCPCS E1700–E1702) and traction equipment (HCPCS E0849, E0855); refer to the Durable Medical Equipment (DME), Prosthetics, Orthotics Grid for authorization and coverage determination.
Follow delegate's prior authorization requirements when delegated
When a delegated entity manages utilization and prior authorization for a Medicare Advantage member, providers must follow the delegate's prior authorization requirements and processes for the affected services.
- Follow the delegate's prior authorization rules for members whose plans delegate utilization management
Verify Part D coverage for oral medications
Oral medications for TMJ may be covered under the member's Part D prescription drug benefit; providers should verify Part D coverage eligibility with the Prescription Solutions customer service department prior to prescribing.
- Contact Prescription Solutions customer service to determine UnitedHealthcare Part D coverage eligibility
Retain documentation and verify member-specific benefits
Providers are expected to retain or have access to appropriate documentation to support coverage determinations and must consult the member-specific benefit plan for coverage, exclusions, and limitations.
- Retain or provide documentation when requested to support medical necessity and coding
- Confirm member-specific benefit plan details via the customer service number or Administrative Guide
Document specific condition/symptom (not just 'TMJ')
Documentation must identify the specific condition or symptom being treated (not merely a diagnosis of 'TMJ') and support that the service is reasonable and necessary under Medicare standards.
- Include the underlying condition or symptom that justifies the service
- Refer to Medicare Benefit Policy Manual, Chapter 15, § 150.1 for dental-related exclusions
Keep and produce supporting documentation; verify benefits
Maintain and be able to produce supporting records and documentation when requested to substantiate coverage, coding, and medical necessity decisions for TMJ-related services.
- Have access to records that demonstrate reasonableness and necessity for services
- Follow member-specific benefit plan documents and applicable laws
Claims listing only 'TMJ' are insufficient
Claims that list a diagnosis of 'TMJ' alone are insufficient; providers must document the underlying condition or symptom to support medical necessity and coverage.
- Ensure claims and supporting documentation specify the actual condition/symptom rather than only 'TMJ'
Responsible for accurate claims and providing documentation on request
Providers are responsible for submitting accurate claims and for supplying appropriate documentation when requested; failure to do so may result in claim denial or adverse coverage decisions.
- Submit claims using applicable CPT/HCPCS and follow coding guidelines
- Provide documentation upon request to support medical necessity
Background
Temporomandibular joint (TMJ) disorders encompass a range of conditions affecting the TMJ and related structures. Management spans conservative approaches—such as medications, injections, and physical therapy—to surgical interventions including arthroplasty and orthognathic procedures. Because some TMJ treatments may fall under Medicare statutory exclusions or lack demonstrated medical necessity, documentation must support the specific condition and rationale for the selected treatment.
Definitions
Revision History
Modified Coverage Rationale heading (removed reference to arthroplasty) and clarified Medicare NCD scope by removing arthroscopy/arthroplasty from the 'no NCD' statement; CPT 21247 removed from applicable codes; previous policy version MMP025.13 archived.
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