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Coverage criteria policies

Temporomandibular Disorder (TMD) Treatments

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Routine in office oral appliances, joint injections, and referrals to physical therapy do not require prior approval when they are directly treating TMD. Please see PT/OT policy for details regarding limitations.

Prior authorization is required for surgical treatment of Temporomandibular disorders (TMD). Open surgical procedures including, but not limited to, arthroplasties, condylectomies, meniscus or disc placation, disc removal and total/partial joint reconstruction with prosthetic implants require prior approval.

Coverage

Temporomandibular Disorder, treatment is generally covered subject to the indications listed below for the ICD-10 diagnosis codes listed below and per your plan documents.

Indications that are covered

The following is a list, though not all inclusive, of services eligible for coverage, provided the services are used to directly treat the temporomandibular disorder.

  1. Non-surgical services generally include:
    1. Physical therapy and modalities.
    2. Oral appliances, such as an occlusal orthotic appliance, must be used to directly treat the temporomandibular disorder. Coverage is limited to one appliance every three years. Note: If the oral appliance is a covered service, per the plan, it is covered under the DME benefit.
    3. Behavior modification/stress management.
    4. Diagnostic imaging (i.e., tomography, cone beam CT scan, arthrography, or MRI).
    5. Steroid and/ or anesthetic injections into the joint or associated muscles.
  2. The following criteria must be met for consideration of coverage for surgical treatment of TMD:
    1. Physical symptoms, including but not limited to pain, impaired TMD range of motion, locking of the jaw.
    2. Observation of TMD instability or dysfunction.
    3. Documentation of 3-6 months conservative treatment when determined appropriate that includes but is not limited to, physical therapy, analgesics, and oral appliances.
    4. Documentation of significant impairment of function and or internal derangement of the joint which is not amenable to improvement with non-surgical care.

Indications that are not covered

  1. Appliances designed to protect the dentition and supporting structures from the effects of bruxism (teeth grinding).
  2. Dental prosthetic and orthodontic appliances.
  3. Dental treatment including but not limited to restorative care, orthodontic care, prosthetic care and oral surgery including orthognathic surgery for treatment of malocclusion or skeletal malrelationship.
  4. Advanced LightWire Functional (ALF) treatment as it is considered investigational.
  5. Nociceptive trigeminal inhibition tension suppression system (NTI-tension suppression system) as it is considered investigational.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Codes

Codes

Description

21010

Arthrotomy, temporomandibular joint

21050

Condylectomy, temporomandibular joint (separate procedure)

21060

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

21110

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

21240

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

21242

Arthoplasty, temporomandibular joint, with allograft

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

CDT Codes

Codes

Description

D7840

Condylectomy

D7850

Surgical Discectomy, With/Without Implant

D7852

Disc Repair

D7854

Synovectomy

D7856

Myotomy

D7858

Joint Reconstruction

D7860

Arthrotomy

D7865

Athroplasty

D7889

Unspecified TMD Therapy, By Report (Must submit with detailed descriptions of services rendered).

D7991

Coronoidectomy

D7880

Occlusal orthotic appliance

D9940

Applies only to bruxism. D7880 should be used for TMD

D7899

Unspecified TMD therapy, by report

D9940

Occlusal guard

ICD-10-CM Codes

Code

Description

M26.60- M26.69

Temporomandibular joint disorders

M26.52

Limited mandibular range of motion

M79.1

Myalgia/Myofascial pain syndrome

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Association for Dental Research. Science Policy-Temporomandibular Disorders (TMD). Adopted, 1996, Revised 2010, Reaffirmed 2015. Retrieved 7/11/2017 from http://www.iadr.org/AADR/About-Us/Policy-Statements/Science-Policy
  2. American Dental Association. Dental Practice Parameters- Temporomandibular (Craniomandibular) Disorders. Adopted /1996, Revised 1997, Reaffirmed 2015. Retrieved 7/11/2017 from http://www.ada.org/en/science-research/dental-practice-/parameters/temporomandibular-craniomandibular-disorders.
  3. American Society of Temporomandibular Joint Surgeons (2001). Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. Retrieved 7/11/2017 from http://www.astmjs.org
  4. Delz, Edwin DDS. (2009). The ALF (Advanced Lightwire Functional Appliance) Creating Facial Beauty and Balance. International Journal of Orthodontics 20(2); 23-27
  5. ECRI Institute. (2013). Efficacy of Treatment for Temporomandibular Joint Disorders. ECRI Institute. Location: Plymouth Meeting, PA., ECRI Institute.
  6. Evans, R., Bassiur, J., and Schwartz, A. (2011). Bruxism, Temporomandibular Dysfunction, Tension-Type Headache, and Migraine. Headache- Journal of the American Headache Society. 51:1169-1172
  7. Friction, J., Look, J., Wright, E., Alencar, F. Chen, H., Lang, M. Ouyang, W. and Velly, A. (2010) Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. Journal of Oralfacial Pain. 24(3):237-254.
  8. Hayes, Inc. Hayes Medical Technology Search and Summary. Physical Therapy for Treatment of Temporomandibular Disorders.Lansdale, PA: Dec. 2014. Hayes, Inc.
  9. Scrivani, S, Mehta, N. Temporomandibular Disorders in Adults. In: Up To Date, Aronson, M (ED), Deschler, D. (Ed). Up To Date, Waltham, MA. (Accessed on July 19, 2016).
  10. Scrivani, S, Keith, D., Kaban, L. (2008). Temporomandibular Disorders. New England Journal of Medicine, 359:2693-2705.
  11. Stapelmann, H. and Turp, J. (2008). The NTI-tss device the therapy of bruxism, temporomandibular disorders, and headache- where do we stand? A qualitative systematic review of the literature. BMC Oral Health Jul 29:8-22

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Policy activity

  • 01/01/1994 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 07/2017
Revision date
  • 07/12/2017

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