Temporomandibular Joint (TMJ) Dysfunction

Section: Visits
Effective Date: July 01, 2018
Revised Date: February 07, 2020
Last Reviewed: January 22, 2020

Description

Dysfunction of the temporomandibular joint (TMJ) can involve hard or soft tissues and may be caused by either organic disease or functional joint abnormalities. Symptoms are varied and include, but not limited to, clicking sounds in the jaw, headaches, trismus, and pain in the ears, neck, arms, and spine.

Criteria

There are three basic approaches to the treatment of TMJ syndrome:

Medical-Surgical:

ANY ONE of the following may be considered medically necessary when a diagnosis of TMJ dysfunction is documented in the medical record.

  • Medical visits; or
  • Arthrocentesis; or
  • Injections of the joint; or
  • Physical medicine (should not exceed four weeks in duration); or
  • Transcutaneous electrical nerve stimulation (TENS); or
  • Arthroscopic procedures; or
  • Diagnostic x-rays taken in conjunction with the treatment of TMJ; or
  • Injection of an anesthetic agent into the trigeminal nerve – allow only once per course of treatment.
  • Manipulation for the reduction of a fracture or dislocation the TMJ, or manipulation of the joint under anesthesia.

Cephalograms and pantograms will be reviewed for medical necessity on an individual consideration basis.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Procedure Codes

21073 21480 21485 21490 29800 29804 64400
70332 70336 70350 70355 70486 70487 70488
97799 E0720 E0730

The following services are considered not medically necessary in the diagnosis of this condition:

  • Electromyography (EMG); and
  • Iontophoresis; and
  • Lateral skull x-rays; and
  • Neuromuscular junction testing; and
  • Somatosensory testing; and
  • Nuclear medicine studies; and
  • Transcranial x-rays; and
  • Ultrasound.

Procedure Codes

70250 70260 76536 78300 78305 95867 95868
95925 95937 97033

Psychiatric/Psychological: TMJ dysfunction is often a psychosomatic condition, usually resulting from tension or stress. Bruxism is a common tension habit which can lead to the TMJ syndrome. Psychiatric/Psychological visits may be considered medically necessary when reported with a diagnosis of TMJ.

TMJ dysfunction may include psychological components such as fear of pain, and depression which may contribute to an exacerbation of symptoms.

Relaxation therapy, electromyographic biofeedback and cognitive behavioral therapy may be considered medically necessary for treatment of TMJ as part of a comprehensive pain management plan.

Relaxation therapy, electromyographic biofeedback, and cognitive behavioral therapy are considered medically necessary in chronic headaches and insomnia, which are frequently associated with TMD/TMJ conditions. The above therapies may be considered medically necessary in treating these conditions as well.

Treatment in multi-disciplinary pain centers may be considered medically necessary in those few individuals who have been unresponsive to less, comprehensive interventions.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Procedure Codes

90875 90876 90901 97124 97140 97127

Mechanical: Any method to alter occlusion of the teeth is considered a mechanical approach. Frequently, an intraoral appliance will be prescribed.

The jaw motion rehabilitation system, Therabite, a manual, hand-held, single patient use device; may be considered medically necessary.

Procedure Codes

D7880 E1700 E1701 E1702

The following may be considered medically necessary for the assessment or of TMJ dysfunction:

  • Arthrogram indicated for pre-surgical evaluation. Arthrogram should not be performed in addition to an MRI scan; or
  • CT scan indicated for hard tissue pre-surgical evaluation; or
  • Muscle testing; or
  • MRI scan indicated for soft tissue pre-surgical evaluation; or
  • Range of motion measurements.

Procedure Codes

64400 70332 70336 70486 70487 70488 95851

The following services are considered not medically necessary therefore non-covered;

  • Kinesiography; and
  • Ultrasonic doppler auscultation; and
  • Vapo-coolent spray (ethyl chloride).

Procedure Codes

97799

Diagnosis Codes

Covered diagnosis codes for procedure codes E1700, E1701, E1702, 29800, 29804, 70332, 70336, 90875, 90876, 90901, 97124, 97140 and 97127

M26.601 M26.602 M26.603 M26.609 M26.611 M26.612 M26.613
M26.619 M26.621 M26.622 M26.623 M26.629 M26.631 M26.632
M26.633 M26.639 M26.69

 

Covered diagnosis codes for 21073, 21480, 21485 and 21490

S01.409A S03.00XA

Professional Statements and Societal Positions Guidelines

NA

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