Treatment of Temporomandibular Joint (TMJ)
Medicare Advantage medical policy governing coverage considerations for diagnosis and treatment of TMJ disorders, including medications, injections, devices, surgeries, and references to related Medicare LCDs/LCAs; applies to UnitedHealthcare Medicare Advantage providers and members.
Routine review; no change to coverage guidelines.
02/01/2026, Summary of Changes = Routine review; no change to coverage guidelines
Coverage Criteria and Policy Scope
Coverage rationale by modality
Coverage guidance and stance vary by treatment modality and applicable CMS NCD/LCD/LCA; where no Medicare NCD/LCD/LCA exists, UnitedHealthcare commercial policy or other referenced policies provide guidance.
Reference: Medicare Benefit Policy Manual, Chapter 15, §150.1
General coverage approach
UnitedHealthcare follows Medicare statutes, regulations, NCDs, and LCDs; where those do not establish criteria, UnitedHealthcare applies internal coverage criteria based on evidence.
Application of dental or orthodontic devices/appliances is not covered when provided for dental purposes, whether or not it accompanies oral and/or orthognathic surgery; such devices are only considered when they are used specifically for the treatment of Temporomandibular Joint (TMJ) disorders. A diagnosis of TMJ alone on a claim is insufficient — the actual condition or symptom must be documented to support medical necessity. Refer to the Medicare Benefit Policy Manual, Chapter 15, §150.1 for Medicare coverage considerations.
Benefit coverage for health services is determined by the member specific benefit plan document. In the event of a conflict, the member specific benefit plan document supersedes this policy. For member-specific coverage information, contact the customer service number on the member ID card or the Administrative Guide.
Some services and appliances used to treat TMJ fall within the Medicare statutory exclusion at §1862(a)(12), which prohibits payment "for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth." When a service falls under this statutory exclusion, it is not payable under Medicare; therefore a claim listing TMJ without documentation of a non‑dental, medically necessary condition or symptom will be insufficient for payment.
This Policy is intended to support UnitedHealthcare coverage decision-making but is not a replacement for Medicare source materials (statutes, regulations, NCDs, LCDs, manuals). Where there is a conflict between this Policy and Medicare source materials, the Medicare source materials apply. Providers should consult the applicable Medicare documents when determining Medicare coverage requirements.
Relevant Procedure and Drug Codes
| 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, requiring bone grafts (includes obtaining autografts) |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, requiring bone grafts (includes obtaining autografts) |
| 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 |
| 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 |
| CPT | References to CPT are used for definitional purposes; providers must follow CPT or other coding guidelines when submitting claims. |
Provider Responsibilities, Prior Authorization, and Documentation
Prior Authorization Required
For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management and prior authorization requirements, follow the delegate's prior authorization and utilization management processes. Confirm prior authorization requirements before scheduling or providing services to avoid denials.
- Affected services may include botulinum toxin injections, sodium hyaluronate injections, corticosteroid injections, durable medical equipment, and other TMJ-related interventions.
- Verify delegate contact information and submission portals for prior authorization.
Clinical Documentation and CMS Reference
Document the specific TMJ-related condition or presenting symptom (e.g., myofascial pain, internal derangement, osteoarthritis) — a diagnosis code of TMJ alone is insufficient for payment. Include history, exam findings, prior conservative therapies and their dates, functional impact, and rationale for the requested service. Where applicable, reference and comply with CMS NCDs, LCDs, LCAs, and the Medicare Benefit Policy Manual, Chapter 15, §150.1 - Treatment of Temporomandibular Joint Syndrome.
- If a CMS LCD/LCA exists (for example for botulinum toxin), include documentation required by that local policy.
- If no NCD/LCD/LCA exists, apply the Coverage Rationale and UnitedHealthcare internal criteria as noted in this policy.
Recordkeeping, Claims, and Coding
Retain all clinical documentation used to support the medical necessity of services and to substantiate claims. Providers are responsible for accurate claim submission using current CPT, HCPCS, and ICD-10 coding and for maintaining records for audit or review.
- Keep copies of operative reports, procedure notes, imaging, progress notes, prior authorization approvals, and correspondence.
- Ensure claims reflect the documented service and include appropriate modifiers and diagnosis pointers when required.
Part D Benefit Verification
Oral medications for TMJ management may be covered under the member's Part D benefit. Verify Part D coverage and member eligibility by contacting Prescription Solutions or the Part D customer service before billing medical benefits for pharmacy-dispensed drugs.
- If medication is covered under Part D, submit pharmacy claims through the Part D prescription benefit rather than medical claims.
- Document Part D verification in the medical record when medication-related medical necessity is cited.
Clinical Background and Policy Context
Temporomandibular joint (TMJ) disorders encompass a variety of conditions affecting the joint and surrounding structures, and a wide range of treatments may be considered. Because many procedures must meet Medicare's "reasonable and necessary" standard under §1862(a)(1) and some interventions are excluded under §1862(a)(12) for services related to teeth or structures directly supporting teeth, a claim listing only "TMJ" is insufficient. Providers must document the specific TMJ condition or symptom and the clinical rationale for the selected treatment to demonstrate that the service is reasonable and necessary.
Key Definitions and References
Policy Changes and Version History
Routine review; archived previous policy version MMP025.11 — no change to coverage guidelines.
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