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Date Printed: June 25, 2017: 01:18 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-12

Original Effective Date: 04/15/02

Reviewed: 04/24/14

Revised: 07/01/15

Subject: Temporomandibular Joint (TMJ) Dysfunction; Diagnosis and Treatment

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Temporomandibular joint (TMJ) dysfunction refers to a group of disorders associated with the temporomandibular joint and musculoskeletal structures, characterized by pain in the TMJ and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of non-surgical and surgical treatment possibilities for individuals whose symptoms persist.

The etiology of TMJ disorders remains unclear and is believed to be multifactorial. TMJ disorders are often divided into two main categories: articular disorders (e.g., ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis and joint dislocation), and masticatory muscle disorders (e.g., myofascial pain, myofibrotic contracture, myospasm, and neoplasia).

There are no generally accepted criteria for diagnosing TMJ disorders. It is often a diagnosis of exclusion and involves physical examination, interview, and dental record review. Diagnostic testing and radiologic imaging is generally only recommended for individuals with severe and chronic symptoms.

Symptoms attributed to TMJ dysfunction are varied and include but are not limited to clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).

For many individuals, symptoms of TMJ dysfunction are short-term and self-limiting. Conservative (non-surgical) therapies, such as eating soft foods, rest, heat, ice, avoiding extreme jaw movements, medications and orthotic appliances (e.g., splint) are recommended prior to consideration of more invasive and/or permanent therapies, such as surgery.

More invasive and/or permanent therapies include manipulation (for reduction of fracture or dislocation of the TMJ), arthrocentesis, arthroscopic surgery, condylectomy, arthroplasty, orthognathic surgery and open surgical procedures.

POSITION STATEMENT:

NOTE: The following services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to TMJ services.

The following procedures meet the definition of medical necessity in the treatment of TMJ dysfunction:

Diagnostic Services:

Non-Surgical Treatments:

NOTE: Orthodontic and restorative services such as crowns, bridges, and restoration of teeth are considered dental services that are subject to coverage available through dental benefits.

Surgical Treatments:

NOTE: Surgical services for TMJ dysfunction meet the definition of medical necessity when there is clinical documentation of symptoms of TMJ dysfunction (intracapsular pathologic conditions or anatomic derangement) and continuous pain unrelieved after 3 – 6 months of conservative (non-surgical) treatment.

The following diagnostic procedures do not meet the definition of medical necessity in the diagnosis of TMJ dysfunction:

The following non-surgical treatments do not meet the definition of medical necessity in the treatment of TMJ dysfunction:

BILLING/CODING INFORMATION:

The following codes may be used to describe services relating to TMJ dysfunction:

CPT Coding:

20605

Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa), without ultrasound guidance

21010

Arthrotomy, temporomandibular joint

21050

Condylectomy, temporomandibular joint

21060

Meniscectomy, partial or complete, temporomandibular joint

21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)

21116

Injection procedure for temporomandibular joint arthrography

21240

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242

Arthroplasty, temporomandibular joint, with allograft

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

29800

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy

29804

Arthroscopy, temporomandibular joint, surgical

HCPCS Coding:

E1700

Jaw motion rehabilitation system (investigational)

E1701

Replacement cushions for jaw motion rehabilitation system, package of six (investigational)

E1702

Replacement measuring scales for jaw motion rehabilitation system, package of 200 (investigational)

REIMBURSEMENT INFORMATION:

Reimbursement for orthotic devices/splints is limited to one (1) maxillary OR one (1) mandibular device in a 6-month period, regardless of type of device or length of time used (e.g., temporary, permanent, day or night, partial, full) and includes all splint adjustments.

Reimbursement for an orthotic device study model is included in the allowance made for the orthotic device/splint.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, radiology report(s), and surgical report (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Arthrocentesis (L29061) and Non-covered Services (L29288), located at fcso.com.

DEFINITIONS:

Ankylosis: stiffness or fixation in a joint caused by disease, injury or surgery.

Joint vibration analysis: sounds and vibrations from the TMJ are recorded and displayed for analysis by clinicians; a diagnostic tool.

Occlusal adjustment: selective grinding of occlusal surfaces of the teeth to eliminate premature contacts and occlusal interferences.

RELATED GUIDELINES:

Orthognathic Surgery, 02-12000-17
Percutaneous Electrical Nerve Stimulation (PENS), 02-61000-03

Transcutaneous Electric Nerve Stimulation (TENS), 02-61000-04

Viscosupplementation, Hyaluronan Injections (e.g. Synvisc®), 09-J1000-22

OTHER:

Mandated Coverage:

Florida statutes, Chapter 641, Section 31094

No health maintenance contract or policy which provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury.

REFERENCES:

  1. Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002778. DOI: 10.1002/14651858. CD002778.pub2.
  2. American Academy of Pediatric Dentistry (AAPD). Guidelines on acquired temporomandibular disorders in infants, children, and adolescents, Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2006. 3.
  3. American Association for Dental Research (AADR). Policy Statement: Temporomandibular joint disorders (TMJ). Accessed at http://www.aadronline.org on 03/27/14.
  4. American Association of Oral and Maxillofacial Surgeons. Statement by the American Association of Oral and Maxillofacial Surgeons Concerning the Management of Selected Clinical Conditions and Associated Clinical Procedures. Temporomandibular Disorders. ©2013. Accessed at http://www.aaoms.org/ on 03/27/14.
  5. American Dental Association; Council on Dental Care Programs (1982).
  6. American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures, 2001. Accessed at http://astmjs.org on 03/27/14.
  7. Atos Medical AB. The TheraBite Jaw Motion Rehabilitation System. Accessed at http://www.atosmedical.com on 03/27/14.
  8. Blue Cross Blue Shield Association Medical Policy. 2.01.21. Temporomandibular Joint Dysfunction (July 2013).
  9. Dynasplint Systems, Inc. Jaw Dynasplint® System. Accessed at http://www.dynasplint.com on 03/27/14.
  10. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Mechanical Stretching Device (Therabite) for Limited Jaw Mobility. Updated 05/25/06.
  11. First Coast Service Options, Inc. (FCSO) Local Coverage Determination (LCD) L29061. Arthrocentesis. (08/19/13).
  12. First Coast Service Options, Inc. (FCSO) Local Coverage Determination (LCD) L29288. Noncovered Services. (03/17/14).
  13. Florida Statute 627.419(7); effective October 01, 1996.
  14. Florida Statute 641.31094. Nondiscrimination of coverage for certain surgical procedures involving bones or joints. Accessed at http://www.flsenate.gov on 03/27/14.
  15. HAYES Medical Technology Directory, “Passive Rehabilitation Therapy for Hypomobility” 09/12/02. Update performed 12/20/05.
  16. Kamstra JI, Roodenburg JLN, Beurskens CHG Reintsema H, Dijkstra PU. TheraBite exercises to treat trismus secondary to head and neck cancer. Support Care Cancer (2013) 21:951–957.
  17. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders, Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003812. DOI: 10.1002/14651858.CD003812.
  18. List T, Axelsson S. Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil 2010; 37(6):430-51.
  19. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder, Phys Ther. July 2006, 86(7): 955-73.
  20. Mina R, Melson P, Powell S, Rao M. Hinze, Passo M, Graham TB, Brunner HI. Effectiveness of Dexamethasone Iontophoresis for Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken). 2011 November ; 63(11): 1511–1516.
  21. National Institute of Dental and Craniofacial Disorders. Less is Often Best in Treating TMJ Disorders. (Accessed 08/17/09).
  22. National Institute of Dental and Craniofacial Disorders. TMJ Disorders. Last updated June 18, 2009. Accessed 08/17/09.
  23. Ren WH, Ao HW, Lin Q, Xu ZG, Zhang B. Efficacy of mouth opening exercises in treating trismus after maxillectomy. Chin Med J 2013;126 (14).
  24. Sharma S, Crow HC, McCall WD, Jr. et al. Systematic review of reliability and diagnostic validity of joint vibration analysis for diagnosis of temporomandibular disorders. J Orofac Pain 2013; 27(1):51-60.
  25. Shi Z, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002970. DOI: 10.1002/14651858. CD002970.
  26. Shi Z, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders (Review). Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
  27. Singh R, Rao K, Anap D, Iyer C, Khatri S. The Short Term Effect of TheraBite® on Temporomandibular Dysfunction: A Case Study. International Journal of Physical Medicine & Rehabilitation.
  28. Statement by the American Association of Oral and Maxillofacial Surgeons Concerning the Management of Selected Clinical Conditions and Associated Clinical Procedures. March 2008.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/24/14.

GUIDELINE UPDATE INFORMATION:

04/15/02

Medical Coverage Guideline Reformatted and revised to include additional coding information and coverage criteria.

10/01/02

Local codes removed.

10/15/02

Revised reimbursement statement regarding orthotic device study models

01/01/03

HCPCS coding update.

02/15/03

Revision of MCG consisting of added descriptive information to clarify orthognathic surgery and arthroplasty of the TMJ.

04/15/03

Revision of MCG consisting of the addition of G0283.

02/15/05

Scheduled review and revision of MCG; consisting of updated references.

01/01/06

Annual HCPCS coding update consisting of the revision of 97024.

02/15/07

Scheduled review and revision of MCG; consisting of updated references.

06/15/07

Reformatted guideline; references updated.

01/01/08

Annual HCPCS coding update consisting of the addition of 21073.

01/21/08

Updated Program Exceptions.

04/21/09

Updated program exception statement, added 70336, 70450, 70460, 70470, 70486, 70487, and 70488.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

10/15/09

Scheduled review; no change in position statement. Revise description section. Update references.

01/01/10

Annual HCPCS coding update: revise descriptors for codes 97032 & 97110. Revised BCBSF Radiology Management program exception section, and updated the references.

03/15/11

Revision; formatting changes.

09/15/11

Revision; formatting changes.

01/01/12

Annual HCPCS coding update. Revised 70355 descriptor.

05/15/14

Revision; updated description section. Revised position statement, CPT coding, HCPCS coding, reimbursement section, program exceptions, definitions and related guidelines section. Updated references and reformatted guideline.

01/01/15

Annual CPT/HCPCS update. Revised 20605 descriptor.

07/01/15

Quarterly CPT/HCPCS update. Deleted code S8262.

Date Printed: June 25, 2017: 01:18 PM