Dysfunction of the temporomandibular joint (TMJ) can involve hard or soft tissues and may be caused by either organic disease or functional joint abnormalities. Symptoms are varied and include, but not limited to, clicking sounds in the jaw, headaches, trismus, and pain in the ears, neck, arms, and spine.
There are three basic approaches to the treatment of TMJ syndrome:
Medical-Surgical: Medical visits, arthrocentesis, and injections of the joint may be considered medically necessary with a diagnosis of TMJ dysfunction.
Physical medicine (including modalities such as heat/cold treatment, manipulation, and electrogalvanic electrical stimulation) may be considered medically necessary as a treatment for TMJ syndrome.
Transcutaneous electrical nerve stimulation (TENS) may be considered medically necessary in the assessment of TMJ dysfunction.
Vapo-coolant spray (ethyl chloride) is a surface (local) anesthetic and will be denied.
Manipulations for the reduction of a fracture, dislocation of the TMJ or manipulation of the joint under anesthesia, are considered surgical procedures. These are inappropriate for treatment of TMJ dysfunction without dislocation and are considered not medically necessary.
Arthroscopic procedures of the TMJ are eligible for payment.
Diagnostic x-rays taken in conjunction with the treatment of TMJ dysfunction are eligible for reimbursement.
Cephalograms and pantograms will be reviewed for medical necessity on an individual consideration basis.
The following services are ineligible for payment on the basis that they are not of proven value in the diagnosis of this condition:
Psychiatric/Psychological: TMJ dysfunction is often a psychosomatic condition, usually resulting from tension or stress. Bruxism is a common tension habit which can lead to the TMJ syndrome. Payment should be made for psychiatric/psychological visits if reported with a diagnosis of TMJ dysfunction.
Mechanical: Any method to alter occlusion of the teeth is considered a mechanical approach. Frequently, an intraoral appliance will be prescribed. The intraoral appliance is excluded from coverage under the medical-surgical programs. Whether performed by a dentist or physician, this approach to the treatment of TMJ syndrome is not eligible for reimbursement.
The jaw motion rehabilitation system, Therabite, a manual, hand-held, single patient use device is eligible for reimbursement.
The following may be considered medically necessary for the treatment of TMJ dysfunction:
NOTE: Major surgical intervention is rarely required in the treatment of TMJ dysfunction. Any claim for a major surgical procedure such as a meniscectomy, arthroplasty, or total condylectomy should be referred for medical review.
NOTE: Additional physical medicine services are eligible only with documentation for individual consideration.
See Medical Policy Bulletin E-1 for information on the eligibility of jaw motion rehabilitation systems.
See Medical Policy Bulletin V-31 for information on Medical Care and Associated Services
See Medical Policy Bulletin Y-1 guidelines regarding physical medicine coverage.
See Medical Policy Bulletin Z-7 for additional guidelines of TENS.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
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