Miscellaneous Section - Temporomandibular
Joint Dysfunction
| Topic: Temporomandibular
Joint Dysfunction |
Last Reviewed Date:
01/2004 |
| Section: Miscellaneous |
Policy No: 68 |
| Revised/Effective Date: 01/2003
|
Next Review Date: 01/2006 |
IMPORTANT INFORMATION
This Dental Policy has been developed through consideration of
generally accepted standards of dental practice, review of dental literature,
dental necessity, and as appropriate, government approval.
Benefit determinations should be based
in all cases on the applicable contract language.
To the extent there are any conflicts between these guidelines and the
contract language, the contract language will control.
The purpose of dental policy is to provide a guide to coverage. Dental
policy is not intended to dictate to providers how to practice dentistry.
Providers are expected to exercise their clinical judgment in providing
the most appropriate care.
|
Description
Temporomandibular Joint Dysfunction (TMD) is
a condition that may be characterized by one or more
of the following symptoms: grating or grinding sensation,
pain on or about the external auditory meatus on palpation,
and stiffness and locking of the jaw. The actual joint
pathology may involve the ligaments, capsule (meniscus)
or osseous structures and can result from either extrinsic
or intrinsic factors leading to condylar displacement,
injury of the meniscus, injury of the ligaments or osteoarthritis
of the condyle and/or fossa. Headaches are not
synonymous with internal derangement of the TMJ or with
TMD, therefore headaches are not covered unless there
is documentation of symtoms or signs of internal derangement
and the above criteria are met.
Policy/Criteria
Procedure is in accordance with generally accepted
standards of dental practice.
Administrative Guidelines
In the review of procedures related to the
diagnosis of Temporomandibular Joint Dysfunction (TMD),
there must be documentation of symptoms other than headache.
Headache, without other symptoms, is not an indication
that TMD pathology is present. Common symptoms associated
with TMD are: crepitus, joint pain, muscle soreness
in the area, clicking, limited opening of the mouth,
limitation of swallowing and chewing, or locking of
the joint.
Procedure |
Description |
Guideline |
| Panoramic Radiograph |
A radiological system that utilizes two axes rotation
to obtain a panoramic view of the dental arches
and their associated structures. |
Allow panorex for the diagnosis of TMD syndrome. |
| Tomograms |
Process tomograms with the diagnosis of TMD
if the clinical symptoms of TMD are present and
non-surgical conservative treatment for bruxism
and malocclusion have failed. Indications for
tomograms include:
- pain specific to the joint,
- crepitus,
- evidence of severe meniscule condylar displacement,
- limitation of motion and
- persistent pain after treatment.
|
Allow if pain persists after treatment. |
| Tomograms (continued) |
Includes full tomographic studies which may involve
eleven films; |
The maximum allowable includes all views as
one study:
- 1 submental view (SMV)
- 3 sagittal views each side teeth closed
- 1 sagittal view each side with maximum opening
- 1 AP view
- 1 transorbital or trans-maxillary view
|
| Arthograms |
An invasive x-ray study of the TMJ. It is the
test to determine perforations in the disc, adhesions
and dynamic function.
Indications for arthrogram include:
- suspected adhesions of the meniscus,
- suspected perforations of the meniscus,
- presence of joint noises,
- pain and failure of conservative therapy,
- meniscus not visible on CT or MRI,
- when CT and MRI do not correlate with the
symptoms and
- dynamic study of the meniscus is needed.
|
Allow for TMD diagnosis. |
| Transcranial x-rays |
These x-rays must be used to document the relationship
between the condyle and the articular disc, and
their relationship to the cranial fossa. X-ray shows
the gross pathology during the diagnosis of TMD
disorders. Usually there are two films taken; one
with jaw open and one with jaw close. |
|
| Magnetic Resonance Imaging (MRI) |
MRI is very useful in the diagnosis of TMD
syndrome in visualizing the joint and is less
invasive than the arthrogram. MRI is not effective
in diagnosing a tear or perforation of the disc
or adhesion of the disc.
Indications for MRI include:
- arthrogram failed to show TMJ disease exists
and symptoms are present,
- suspected neoplasms of the joint and
- post surgical complications.
|
MRI is an allowed procedure. |
| Cat Scan |
Cat Scan should be performed when all other forms
of testing have been negative for TMD and symptoms
continue to persist. |
By report, allow when all sources of pain have
been ruled out by customary means and pathology
outside the joint is suspected. |
| Cephalogram |
Cephalometric x-rays taken of the jaws and skull
for the purpose of taking measurements used in oral
surgery and orthodontics, and include scientific
measurements of the cranium and the facial bones. |
No benefit. |
| Full mouth x-rays |
Full mouth x-rays |
Full mouth xrays are not medically necessary. |
Process to TMD benefits:
The following diagnostic procedures (non-surgical),
conservative therapy may consist of pain medication,
anti-inflammatory medications, physical therapy (PT),
self-applied hot and cold packs, TENS manipulation,
splint therapy, etc.
Procedure |
Description |
Guideline |
| Physical Therapy (PT) |
Approved service for the treatment
of TMD. Follow the PT guidelines. |
Dentists are eligible to do PT on
and around the cervical region and facial muscles,
head and neck. |
| Manipulation of the jaw |
For the treatment of TMD has not been determined
to be medically effective. EXCEPT when there is
an acute traumatic dislocation of the joint and
a reduction is performed under anesthesia. Accident
benefits may be applied, using CPT codes 21480 and
21485 |
|
| TENS |
TENS units are not considered medically necessary
to control TMD pain; therefore not eligible as DME.
|
TENS treatment and ultrasound treatment by the
PT or dentist are considered medically effective;
therefore eligible for benefits according to contract
language and limitations. |
| Electromyograph (EMG) |
Used to measure the bioelectric activity in the
muscle and indicates muscle spasm. It has not been
found to directly impact the diagnosis or the treatment
of the TMD condition. |
EMG is to be denied as investigational since medical
necessity not established |
| Mandibular Kineosiography (MKG) |
This instrument measures movement of the mandible
in three dimensions simultaneously and records the
movement photographically for permanent records.
It documents craniomandibular dysfunction. This
procedure has not been proven to have a direct effect
on the diagnosis or treatment of TMD. |
Deny MKG as investigational since medical necessity
not established |
| Acupuncture |
Acupuncture is appropriate for the diagnosis of
Myofacial Pain. It is not appropriate for the diagnosis
of internal derangement of TMD syndrome without
the additional diagnosis of myofacial pain syndrome. |
Deny as medical effectiveness not established. |
| Manual assisted exerciser |
Is a device providing manually assisted exercise
during which mandibular motion is guided along a
physiologically correct pathway. The device is used
at home as a supplement for PT in the early post-operative
period. The device is a one-time purchase for each
individual patient. Manual assisted exerciser is
considered to be medically appropriate for the post-operative
period following surgical procedures of the TMD.
It may be used for the immediate post-operative
period. |
|
| Continuous passive motion |
Usually performed in the immediate post-operative
period has not been proven to be medically necessary
effective in the post-operative period. |
Not eligible for benefits. |
Process to TMD benefits:
The following are arthroscopy procedures;
arthroscopy is an invasive procedure using an arthoscope
and can be a diagnostic or surgical procedure.
Procedure |
Description |
Guideline |
| Arthroscopy, diagnostic: |
Allowed when other forms of testing
have been inconclusive. If there is another arthoscopic
procedure, it is considered incidental. If diagnostic
arthroscopy precedes an open arthrotomy, it is
considered a secondary procedure and will be processed
with multiple procedure guidelines.
|
By report. Indications for arthroscopy
surgery include:
- Anterior disc displacement – without
reduction, with pain.
- Anterior disc displacement – with reduction,
with pain, with deformed disc.
- Anterior disc displacement – with reduction,
with pain, young patient with mandibular dysfunction.
- Fibrous adhesions in the upper or lower joint
compartment.
- Normal mandibular function, but with disc
perforation, with or without osteoarthritic
changes.
- Foreign body visible on x-rays.
|
| Arthroscopy, surgical: |
Should be attempted only after other forms of
non-surgical therapy have failed. |
The procedure will be by report. |
| Arthroscopy, surgical assistant: |
Deny as medical necessity not established. |
|
| Arthroscopic lysis of adhesions or debridement,
and lavage: |
Deny as incidental if performed in conjunction
with another arthroscopic procedure or open surgical
procedure. |
|
| Arthroscopic repair or reconstruction of the meniscus/
disc: |
By report, to establish medical necessity. Referral
should be accompanied by the operative report. |
|
Process to TMD benefits:
Surgical intervention to treat TMD may include
arthroplasty, coronoidectomy, meniscectomy, condylectomy,
joint or articular disc replacement
Procedure |
Description |
Guideline |
| Arthroplasty: |
Indications for arthroplasty include:
- Displaced or torn meniscus.
- Presence of spurs, necrosis of the condyle;
or arthritic deterioration.
- Failure of conservative therapy over at least
6 months; positive arthrogram or MRI.
- Failure of medical treatment and evidence
of severe joint disease.
- Ankylosis present.
|
By report: All documentation needed for review
should include reports from all results of testing
performed, conservative treatment, history and physical
and operative reports from previous procedures performed
on the TMJ. |
| Meniscectomy, disc plication, condylectomy: |
Are all considered incidental to the arthroplasty.
If performed individually without the arthroplasty
they may be reimbursed at full maximum allowable.
CPT defines these codes "separate procedure."
|
Deny if billed in combination with other codes
for the same joint. |
| Coronoidectomy: |
Coroidectomy is usually performed through a separate
incision from the arthroplasty. This incision is
made in the oral cavity. |
Bilateral procedure will be reviewed and processed
using the multiple procedure guidelines. |
| Replacement of the articular disc/meniscus: |
Articular disc removal is determined at the time
of arthroplasty. |
All replacement grafts for the articular disc
of the TMJ will be included in the arthroplasty,
therefore, not eligible for additional benefits. |
| Total joint replacement: |
They must be FDA approved if they are a device.
Autografts for total joint replacement must be published
and reviewed in peer-reviewed journals and be in
accordance with accepted medical practice in the
community. |
All total joint replacement must be pre-authorized. |
| Microvascular second metatarsophalangeal total
joint transplant: |
Consists of removing the entire second metatarsal
and phalangeal joint for transplantation and reconstruction
of the TMJ. A microvascular anastamosis is performed,
attaching the dorsal pedis artery to a facial artery
and veins. |
This procedure is considered experimental and
investigational; therefore not eligible for benefits.
|
Process to TMD benefits:
The following are occlusal orthotic devices.
The types of splints used for splint therapy are diagnostic,
repositioning, pain control and bruxism splints. Diagnostic
and repositioning splints are used in the diagnosis
and treatment of TMD. Bruxism splints are not directly
related to TMD but are very often mistaken as being
the same as diagnostic and repositioning splints.
Procedure |
Description |
Guideline |
| Diagnostic splint/acute pain reduction in TMD:
|
The diagnostic/acute pain reduction splints are
not associated with myofacial pain syndrome (MFPS).
|
This splint is considered medical/TMD. During
the use of this splint PT modalities are very often
used. Multiple adjustments may be necessary as normal
function returns. See review procedure below. |
| Splint for treatment of MFPS, not TMD: |
This splint is prescribed for the treatment of
myofacial pain not associated with TMD. |
This splint will be processed as medical. |
| Repositioning splint: |
This splint is designed from the measurements
and information gathered. The splint is created
AFTER acute pain and spasm have been determined.
This splint is more sophisticated in its adjustment.
The purpose of the splint is to establish a functional
relaxed muscle/jaw relationship for stabilization.
If no relief in six months, the patient is to
be re-evaluated. |
Review procedure for diagnostic and repositioning
splints include:
- Establish medical necessity.
- Any future replacement splints will be reviewed
on an individual consideration if outside the
six months global period of a previous splint.
|
| Bruxism splint: |
This splint is used to prevent periodontal
breakdown, abnormal abrasion of the teeth and
pain in the TMD caused by clenching or grinding
of the teeth. Occlusal guard in the case of periodontal
breakdown must be accompanied by documentation
of periodontal treatment. This splint is also
used to stop the muscular effects of bruxism (muscle
pain and soreness), and would be considered dental.
|
- Refer to dental policy for bruxism splint
(occlusal guard D9940)
- When splints are billed as a package with
therapy, allow as TMD, according to the contract’s
TMD benefits.
- Mandibular repositioning sleep device, snore
guard, etc., for sleep apnea: refer to medical
policy for sleep apnea
|
| Dental services which are not eligible for medical
benefits under TMD guidelines are: |
- Occlusal equilibration
- Full mouth reconstruction
- Dentures
- Orthodontia
- Appliance or restoration to increase vertical
dimension or restore occlusion.
|
|
| List
of Valid ADA (Dental) Codes to Use for Processing
TMD Claims Billed by a Dental Provider |
| Codes |
Number |
Description |
| CDT |
D0160 |
Detailed and Extensive Oral Evaluation
- Problem Focused, By Report |
| |
D0320 |
Temporomandibular Joint Arthrogram,
Including Injection |
| |
D0321 |
Other Temporomandibular Joint Films, By Report |
| |
D0322 |
Tomographic Survey |
| |
D0470 |
Diagnostic Casts (Study Models) |
| |
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 |
| |
D7850 |
Myotomy |
| |
D7858 |
Joint Reconstruction |
| |
D7860 |
Arthrotomy |
| |
D7865 |
Athroplasty |
| |
D7870 |
Arthrocentesis |
| |
D7871 |
Non - Arthroscopic Lysis and Lavage |
| |
D7872 |
Arthroscopy - Diagnosis, With or Without Biopsy |
| |
D7873 |
Arthroscopy - Surgical: Lavage and Lysis of Adhesions |
| |
D7874 |
Arthroscopy - Surgical: Disc Respositioning and
Stabilization |
| |
D7875 |
Arthoscopy - Surgical: Synovectomy |
| |
D7877 |
Arthoscopy - Debridement |
| |
D7880 |
Occlusal Orthotic Device, By Report |
| |
D7889 |
Unspecified TMD Therapy, By Report (Please submit
with detailed descriptions of services rendered). |
| |
D7991 |
Coronoidectomy |
| |
D9940 |
Does not apply to TMD. Use D7880 |
| |
D9950 |
Occlusion analysis - Mounted Case |
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