Clinical UM Guideline

 

Subject: Temporomandibular Disorders
Guideline #:  CG-SURG-09 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018

Description

This document addresses temporomandibular joint (TMJ) and related musculoskeletal structure disorders commonly called temporomandibular disorders (TMD), a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, and craniomandibular disorder (CMD).

Note: Please refer to the following documents for additional information concerning related topics:

Clinical Indications

Medically Necessary:

Nonsurgical treatments considered medically necessary for temporomandibular disorders include the following:

  1. Reversible, removable, intraoral appliances such as removable splints;
  2. Pharmacologic therapy (that is, analgesics, anti-inflammatory drugs, and muscle relaxants);
  3. Physical therapy;
  4. Therapeutic injections.

Surgical procedures considered medically necessary for temporomandibular disorders when criteria A and B listed below are met include the following:

  1. Arthrocentesis;
  2. Arthroscopic surgery;
  3. Manipulation for reduction of fracture or dislocation;
  4. Open surgical procedures, including arthroplasty, condylectomy, modified condylotomy, disc or meniscus plication, and disc removal when the temporomandibular disorder is the result of congenital anomalies, disease, or trauma;
  5. TMJ arthroplasty with prosthetic implants may be considered for U.S. Food and Drug Administration (FDA) approved prostheses only.

Criteria A and B:

  1. Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by BOTH of the following:
    1. Completion of skeletal growth for individuals under age 18 with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Note: individuals age 18 and older do not require this documentation); and
    2. Computed tomography (CT), magnetic resonance imaging (MRI), or x-ray of the temporomandibular joint documents joint pathology (for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);
      and
  2. Temporomandibular joint pain or a clinically significant functional impairment, NOT due to a maxillary/mandibular skeletal deformity and refractory to at least six months of non-surgical treatment to include at least ONE of the following:
    1. Behavioral therapy; or
    2. Pharmacologic therapy (that is, analgesics, nonsteroidal anti-inflammatory drugs, muscle relaxants); or
    3. Physical therapy; or
    4. Reversible, removable, intraoral appliances such as removable splints; or
    5. Therapeutic injections.

Not Medically Necessary:

Nonsurgical treatments considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

  1. Biofeedback;
  2. Dental devices for joint range of motion or for development of muscles used in jaw function;
  3. Dental prostheses (for example, dentures; implants);
  4. Dental restorations (for example, bridgework; crowns);
  5. Electrogalvanic stimulation (EGS);
  6. Iontophoresis;
  7. Occlusal equilibration, bite adjustment, irreversible occlusion therapy;
  8. Orthodontic services such as braces and application of a mandibular advancement repositioning device.

Surgical procedures considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

  1. Dental implants;
  2. Dental restorations;
  3. Extraction of wisdom teeth;
  4. Orthodontic services;
  5. TMJ arthroplasty implants that are not FDA approved.

Diagnostic Testing:

The following procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

  1. Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning);
  2. Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning);
  3. Electromyography (including percutaneous or surface electrode methods);
  4. Kinesiography;
  5. Somatosensory testing/neuromuscular junction testing;
  6. Sonogram (ultrasonic Doppler auscultation);
  7. Standard dental x-rays;
  8. Thermography;
  9. Transcranial or lateral skull x-ray.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

 

Including, but not limited to, the following:

20605

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

20606

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

21010

Arthrotomy, temporomandibular joint

21050

Condylectomy, temporomandibular joint (separate procedure)

21060

Meniscectomy, partial or complete, temporomandibular joint (separate procedure)

21073

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

21110

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21116

Injection procedure for temporomandibular joint arthrography

21210

Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

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 (separate procedure)

29804

Arthroscopy, temporomandibular joint, surgical

 

 

HCPCS

 

D7810

Open reduction of dislocation

D7820

Closed reduction of dislocation

D7830

Manipulation under anesthesia

D7840

Condylectomy

D7850

Surgical discectomy, with/without implant

D7852

Disc repair

D7854

Synovectomy

D7856

Myotomy

D7858

Joint reconstruction

D7860

Arthrotomy

D7865

Arthroplasty

D7870

Arthrocentesis

D7871

Nonarthroscopic lysis and lavage

D7873

Arthroscopy- surgical: lavage and lysis of adhesions

D7874

Arthroscopy- surgical: disc repositioning and stabilization

D7875

Arthroscopy- surgical: synovectomy

D7876

Arthroscopy- surgical: discectomy

D7877

Arthroscopy- surgical: debridement

D7880

Occlusal orthotic appliance

D7899

Unspecified TMD therapy, by report

D9940

Occlusal guards, by report

D9950

Occlusion analysis- mounted case

D9951

Occlusal adjustment- limited

D9952

Occlusal adjustment- complete

E1700

Jaw motion rehabilitation system

E1701

Replacement cushions for jaw motion rehabilitation system, package of 6

E1702

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

 

 

ICD-10 Procedure

 

0RBC0ZZ

Excision of right temporomandibular joint, open approach

0RBC3ZZ

Excision of right temporomandibular joint, percutaneous approach

0RBC4ZZ

Excision of right temporomandibular joint, percutaneous endoscopic approach

0RBD0ZZ

Excision of left temporomandibular joint, open approach

0RBD3ZZ

Excision of left temporomandibular joint, percutaneous approach

0RBD4ZZ

Excision of left temporomandibular joint, percutaneous endoscopic approach

0RQC0ZZ-0RQC4ZZ

Repair right temporomandibular joint [includes codes 0RQC0ZZ, 0RQC3ZZ, 0RQC4ZZ]

0RQD0ZZ-0RQD4ZZ

Repair left temporomandibular joint [includes codes 0RQD0ZZ, 0RQD3ZZ, 0RQD4ZZ]

0RSC04Z-0RSCXZZ

Reposition right temporomandibular joint [includes codes 0RSC04Z, 0RSC0ZZ, 0RSC34Z, 0RSC3ZZ, 0RSC44Z, 0RSC4ZZ, 0RSCX4Z, 0RSCXZZ]

0RSD04Z-0RSDXZZ

Reposition left temporomandibular joint [includes codes 0RSD04Z, 0RSD0ZZ, 0RSD34Z, 0RSD3ZZ, 0RSD44Z, 0RSD4ZZ, 0RSDX4Z, 0RSDXZZ]

0RUC07Z-0RUC4KZ

Supplement right temporomandibular joint [includes codes [0RUC07Z, 0RUC0JZ, 0RUC0KZ, 0RUC37Z, 0RUC3JZ, 0RUC3KZ, 0RUC47Z, 0RUC4JZ, 0RUC4KZ]

0RUD07Z-0RUD4KZ

Supplement left temporomandibular joint [includes codes 0RUD07Z, 0RUD0JZ, 0RUD0KZ, 0RUD37Z, 0RUD3JZ, 0RUD3KZ, 0RUD47Z, 0RUD4JZ, 0RUD4KZ]

 

 

ICD-10 Diagnosis

 

G44.89

Other headache syndrome

M19.91

Primary osteoarthritis, unspecified site

M26.50-M26.59

Dentofacial functional abnormalities

M26.601-M26.69

Temporomandibular joint disorders

M79.1

Myalgia

S03.0XXA-S03.0XXS

Dislocation of jaw [includes codes S03.0XXA, S03.0XXD, S03.0XXS]

Discussion/General Information

Temporomandibular disorders (TMD) is a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndromes, and craniomandibular disorder (CMD), that includes a variety of medical and dental conditions involving the masticatory muscles and the temporomandibular joint, as well as contiguous tissue components. It is not known how many people have TMD, but the main symptoms of pain and restricted jaw movement occur in 5-15 percent of afflicted Americans and more frequently affect women. Although some cases can be linked to physical trauma or disease conditions, in most cases the cause is unknown.

The most frequent presenting symptom associated with TMD is pain, usually localized to the muscles of mastication, the preauricular area, and/or the TMJ. This pain may be related to trauma, (such as a blow to the face), inflammatory or degenerative arthritis, or may be due to the mandible being pushed back towards the ears whenever the individual chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening the mouth normally. Other common complaints reported by individuals include earache, headache, and facial pain. Individuals may also have limited or asymmetric jaw movement and joint sounds that are usually described as clicking, popping, grating, or crepitus in the TMJ.

Conservative therapy is the mainstay in treating TMD. This therapy may include behavioral change, oral medications for pain, anti-inflammatory injections, and orthotic devices. Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. According to the National Institute of Dental and Craniofacial Research (NIDCR), there are no standards to identify people who would most likely benefit from surgery (NIDCR, 2010). A review of available published evidence regarding the safety and efficacy of various medical and surgical treatment modalities for TMJ revealed inconsistent methodologies in study design and a significant variation of improved clinical outcomes (Al-Moraissi, 2017; Bouchard, 2017; Fricton, 2010; Kuzmanovic Pficer, 2017; List, 2010; Schiffman, 2007; Tatli, 2017; Truelove, 2006).

In 2014, Schiffman and colleagues found that, although the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been reliable, they were below the target sensitivity of greater than or equal to 0.70 and specificity of greater than or equal to 0.95. This empirical finding prompted a revision. The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I include both a valid screening protocol for detecting any pain-related TMD, as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity greater than or equal to 0.86, specificity greater than or equal to 0.98). The authors stated:

TMD is the second most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability… Taken together, a new dual-axis Diagnostic Criteria for TMD (DC/TMD) will provide evidence-based criteria for the clinician to use when assessing patients, and will facilitate communication regarding consultations, referrals, and prognosis.

In 2017, the American Academy of Oral and Maxillofacial Surgeons (AAOMS) issued Parameters of Care (6th edition) which provided the following:

Temporomandibular joint (TMJ) surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection…Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient.

Several devices that have obtained pre-market approval/clearance (PMA) from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD include, but are not limited to, the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis (TMJ Concepts, Camarillo, CA); the TMJ Partial Temporomandibular Joint Replacement System, TMJ Fossa-Eminence Prosthesis System and the TMJ Patient Specific Fossa-Eminence Prosthesis System (TMJ Implants, Inc., Golden, CO); and the Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation [formerly Walter Lorenz Surgical, Inc.], Jacksonville, FL). The FDA-approved labeling for each of these devices has similar indications, however, to date, the published evidence to support safety, efficacy, and durability of clinical outcomes has been limited.

Definitions

Analgesics: Medications that provide pain relief.

Arthroplasty: Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.

Behavioral therapy: Therapy aimed to help people examine those behaviors and emotions that have a negative impact on their lives and make a conscious effort to bring about positive changes.

Craniomandibular disorder (CMD): A dental term used to describe diseases or disorders of the muscles of the head and neck, with special reference to the masticatory (chewing) muscles.

Disc: Shortened terminology for an intervertebral disc or a TMJ disc; a disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones.

Mandible: Bone of the lower jaw.

Meniscus: A cartilage pad between the two joint surfaces within the TMJ, acting as a smooth surface for the joint to move on.

Modified condylotomy: An extra-articular surgical procedure used to manage TMJ dysfunction. The primary purpose of the procedure is to increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence.

Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.

Physical therapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help individuals regain or improve their physical abilities.

Temporal bone: A large, irregular bone situated at the base and side of the skull; connected with the mandible via the TMJ.

Temporomandibular joint (TMJ): Joint that hinges the mandible to the temporal bone of the skull; one of the most frequently used joints in the entire body, moving whenever a person eats, drinks, or talks.

References

Peer Reviewed Publications:

  1. Al-Belasy FA, Dolwick MF. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. Int J Oral Maxillofac Surg. 2007; 36(9):773-782.
  2. Albury CD Jr. Modified condylotomy for chronic nonreducing disk dislocations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997; 84:234.
  3. Bouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular lavage versus nonsurgical treatments for temporomandibular disorders: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(7):1352-1362.
  4. Bouloux GF. Modified condylotomy for temporomandibular joint dysfunction. Atlas Oral Maxillofac Surg Clin North Am. 2011; 19(2):169-175.
  5. Ebrahimi A, Ashford BG. Advances in temporomandibular joint reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2010; 18(4):255-260.
  6. Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: A systematic review and meta-analysis. J Am Dent Assoc. 2012; 143(8):847-857.
  7. Fricton J, Look JO, Wright E, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain. 2010; 24(3):237-254.
  8. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005; 63(8):1174-1179.
  9. Hall HD, Navarro EZ, Gibbs JS. One- and three year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg. 2000; 58(1):7-17.
  10. Hall HD, Werther JR. Results of reoperation after failed modified condylotomy. J Oral Maxillofac Surg. 1997; 55(11):1250-1253.
  11. Keller EE, Baltali E, Liang X, et al. Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study. J Oral Maxillofac Surg. 2012; 70(2):276-288.
  12. Kuzmanovic Pficer J, Dodic S, Lazic V, et al. Occlusal stabilization splint for patients with temporomandibular disorders: meta-analysis of short and long term effects. PLoS One. 2017; 12(2). Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0171296. Accessed on February 12, 2018.
  13. Lindenmeyer A, Sutcliffe P, Eghtessad M, et al. Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review. J Oral Maxillofac Surg. 2010; 68(11):2755-2764.
  14. Linsen SS, Reich RH, Teschke M. Mandibular kinematics in patients with alloplastic total temporomandibular joint replacement-a prospective study. J Oral Maxillofac Surg. 2012; 70(9):2057-2064.
  15. List T, Axelsson S. Management of TMD: Evidence from systematic reviews and meta-analyses. J Oral Rehab. 2010; 37(6):430-451.
  16. Manfredini D, Rancitelli D, Ferronato G, Guarda-Nardini L. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil. 2012; 39(4):245-251.
  17. Marbach, JJ. Temporomandibular pain and dysfunction syndrome: history, physical examination, and treatment. Rheumatic Dis Clin of North Am. 1996; 22(3):477-498.
  18. McKenna SJ. Modified mandibular condylotomy. Oral Maxillofacial Surg Clin N Am. 2006; 18(3):369-381.
  19. McKenna SJ, Cornelia F, Gibbs SJ. Long-term follow-up of modified condylotomy or internal derangement of the TM joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endo. 1996; 81:509.
  20. McLeod NM, Saeed NR, Hensher R. Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis. Br J Oral Maxillofac Surg. 2001; 39(1):63-66.
  21. Al-Moraissi EA, Wolford LM, Perez D, et al. Does orthognathic surgery cause or cure temporomandibular disorders? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(9):1835-1847.
  22. Park J, Keller EE, Reid KI. Surgical management of advanced degenerative arthritis of temporomandibular joint with metal fossa-eminence hemijoint replacement prosthesis: an 8-year retrospective pilot study. J Oral Maxillofac Surg. 2004; 62(3):320-328.
  23. Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007; 86(1):58-63.
  24. Tatli U, Benlidayi ME, Ekren O, Salimov F. Comparison of the effectiveness of three different treatment methods for temporomandibular joint disc displacement without reduction. Int J Oral Maxillofac Surg. 2017; 46(5):603-609.
  25. Truelove E, Huggins KH, Manci L, Dworkin SF. The efficacy of traditional, low cost, and non-splint therapies for temporomandibular disorder. J Am Den Assoc. 2006; 137(8):1099-1107.
  26. Vos LM, Huddleston Slater JJ, Stegenga B. Lavage therapy versus nonsurgical therapy for the treatment of arthralgia of the temporomandibular joint: a systematic review of randomized controlled trials. J Orofac Pain. 2013; 27(2):171-179.
  27. Werther JR, Hall HD, Gibbs JS. Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):668-679.
  28. Widmalm S, Brooks S, Sano T, et al. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol. 2006; 35(5):334-338.
  29. Wolford LM. Factors to consider in joint prosthesis systems. Proc (Bayl Univ Med Cent). 2006; 19(3):232-238.
  30. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of two temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg. 2003a; 61(6):685-690.
  31. Wolford LM, Pitta MC, Reiche-Fishel O. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003b; 32(3):268-274.
  32. Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(6):671-675.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Oral and Maxillofacial Surgery (AAOMS). Parameters of care: clinical practice guidelines for oral and maxillofacial surgery (AAOMS ParCare 2017) temporomandibular joint surgery. 6th ed. 2017. Available at: https://www.aaoms.org/docs/member-center/parcare/parcare_8_temporomandibular.pdf.  Accessed on February 8, 2018.
  2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical condition statements: temporomandibular disorders. 2017. Available at: http://www.aaoms.org/practice-resources/aaoms-advocacy-and-position-statements/clinical-resources. Accessed on February 8, 2018.
  3. American Association for Dental Research (AADR). Policy statement: temporomandibular joint disorders (TMJ). Adopted 1996; reaffirmed 2015. Available online at: http://www.iadr.org/AADR/About-Us/Policy-Statements/Science-Policy#TMD. Accessed on February 8, 2018.
  4. American Society of Temporomandibular Joint Surgeons (ASTMJS). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Revised 2001. Available at: http://www.astmjs.org/final%20guidelines-04-27-2005.pdf. Accessed on February 8, 2018.
  5. de Souza RF, Lovato da Silva CH, Nasser M, et al. Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012; (4):CD007261. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007261.pub2/abstract. Accessed on February 8, 2018.
  6. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2001; (1):CD000979. Available at: http://onlinelibrary.wiley.com/doi/10.1002/‌14651858.CD000979.pub2/‌abstract. Accessed on February 8, 2018.
  7. National Institute of Dental and Craniofacial Research (NIDCR). TMJ disorders. Updated September 2017. Available at: https://www.nidcr.nih.gov/oralhealth/Topics/TMJ/TMJDisorders.htm. Accessed on February 8, 2018.
  8. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network (International Association for Dental Research) and Orofacial Pain Special Interest Group (International Association for the Study of Pain). J Orol Fac Pain Headache. 2014; 28(1):6-27.
  9. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis System Summary of Safety and Effectiveness. No. P980052. Rockville, MD: FDA. July 2, 1999. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P980052B.pdf. Accessed on February 8, 2018.
  10. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Partial Temporomandibular Joint Replacement System; TMJ Fossa-Eminence Prosthesis System and TMJ Patient Specific Fossa-Eminence Prosthesis System Summary of Safety and Effectiveness. No. P000035. Rockville, MD: FDA. February 27, 2001. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P000035B.pdf. Accessed on February 8, 2018.
  11. U.S. Food and Drug Administration (FDA) Premarket Notification Database. TMJ Metal-on-Metal Total Temporomandibular Joint Replacement System; TMJ Fossa Eminence/Condylar Prosthesis System Summary of Safety and Effectiveness. No. P000023. Rockville, MD: FDA. January 5, 2001. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf/P000023B.pdf. Accessed on February 8, 2018.
  12. U.S. Food and Drug Administration (FDA) Premarket Notification Database. Walter Lorenz Total Temporomandibular Joint (TMJ) Replacement System Summary of Safety and Effectiveness. No. P020016. Rockville, MD: FDA. September 21, 2005. Available at: https://www.accessdata.fda.gov/‌cdrh_docs/pdf2/P020016B.pdf. Accessed on February 8, 2018.
  13. White SC, Heslop EW, Hollender LG, et al. Parameters of radiologic care: an official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(5):498-511.
Index

Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
Temporomandibular Joint
TMJ
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis
TMJ Fossa-Eminence Prosthesis System
Total Temporomandibular Joint (TMJ) Replacement System

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.

History

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Discussion/General Information and References sections updated.

Revised

05/04/2017

MPTAC review. Modified condylotomy was added to the surgical procedures for TMD considered medically necessary when criteria are met. References and Coding sections were updated.

Reviewed

11/03/2016

MPTAC review. Updated the formatting of the Clinical Indications section. The Discussion section and References were updated.

 

10/01/2016

Updated coding section with 10/01/2016 ICD-10-CM changes.

Reviewed

11/05/2015

MPTAC review. References were updated. Removed ICD-9 codes from Coding section.

 

07/01/2015

Updated Coding section with 07/01/2015 HCPCS changes; removed S8262 deleted 06/30/2015.

Reviewed

11/13/2014

MPTAC review. Discussion and References sections were updated. Updated Coding section with 01/01/2015 CPT changes.

Reviewed

11/14/2013

MPTAC review. Discussion section and References were updated.

Reviewed

11/08/2012

MPTAC review. References were updated.

Reviewed

11/17/2011

MPTAC review. Discussion and References were updated.

Revised

11/18/2010

MPTAC review. Revised Subject of document to: Temporomandibular Disorders. Clarified wording throughout the Clinical Indications, changing ‘temporomandibular dysfunction’ to ‘temporomandibular disorders.’ Revised medically necessary criteria for surgical intervention specific to the age requirement for documented radiograph proof of completion of skeletal growth as follows: “Completion of skeletal growth for individuals under age 18 with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Note: individuals age 18 and older do not require this documentation).” Alphabetized, formatted and reordered document Clinical Indications without additional revisions to the document criteria. Updated Description, Coding, Discussion, Definitions, and References.

 

10/01/2010

Updated Coding section with 10/01/2010 ICD-9 changes.

Reviewed

11/19/2009

MPTAC review. Updated References and Coding.

Reviewed

11/20/2008

MPTAC review. Updated Discussion and References.

Reviewed

11/29/2007

MPTAC review. Updated References and Coding to include 01/01/2008 CPT changes.

Reviewed

12/07/2006

MPTAC review. Updated References.

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

N/A

N/A

N/A

Anthem Northeast (Maine)

None

BD

TMJ (Temporomandibular Joint Syndrome) Benefit Detail

Anthem Midwest

08/06/2004

MA-037

Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ, Craniomandibular Disorder (CMD)

WellPoint Health Networks, Inc.

09/23/2004

Clinical Guideline

Temporomandibular Joint Arthroplasty