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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.


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




Arthrotomy, temporomandibular joint


Condylectomy, temporomandibular joint (separate procedure)


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


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


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


Arthoplasty, temporomandibular joint, with allograft


Arthroplasty, temporomandibular joint, with prosthetic joint replacement


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

CDT Codes






Surgical Discectomy, With/Without Implant


Disc Repair






Joint Reconstruction






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




Occlusal orthotic appliance


Applies only to bruxism. D7880 should be used for TMD


Unspecified TMD therapy, by report


Occlusal guard

ICD-10-CM Codes



M26.60- M26.69

Temporomandibular joint disorders


Limited mandibular range of motion


Myalgia/Myofascial pain syndrome

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


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.


  1. American Association for Dental Research. Science Policy-Temporomandibular Disorders (TMD). Adopted, 1996, Revised 2010, Reaffirmed 2015. Retrieved 7/11/2017 from
  2. American Dental Association. Dental Practice Parameters- Temporomandibular (Craniomandibular) Disorders. Adopted /1996, Revised 1997, Reaffirmed 2015. Retrieved 7/11/2017 from
  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
  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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