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. TMJ dysfunction may include psychological components such as fear of pain, and depression which may contribute to an exacerbation of symptoms.
There are three (3) basic approaches to the treatment of TMJ dysfunction:
Medical-Surgical:
When an individual has a diagnosis of TMJ dysfunction, ANY of the following may be considered medically necessary:
Cephalograms and pantograms will be reviewed for medical necessity on an individual consideration basis.
Diagnostic x-rays taken in conjunction with the treatment of TMJ dysfunction are eligible for reimbursement. Claims reporting such x-rays should be processed under the appropriate diagnostic radiology code (the 70000 series). Specifically excluded from coverage are the dental radiography codes (D0210-D0350).
Services that do not meet the criteria of this policy will be considered not medically necessary.
20605 |
20606 |
21010 |
21089 |
21073 |
21480 |
21485 |
21490 |
29800 |
29804 |
64400 |
70488 |
97024 |
97110 |
97112 |
97124 |
97140 |
97530 |
97799 |
E0720 |
E0730 |
The following services are considered not medically necessary in the diagnosis of TMJ:
95867 |
95868 |
95925 |
95937 |
97033 |
|
|
Occlusal Guards:
Treatment with occlusal guards is considered not medically necessary.
D9944 |
D9945 |
D9946 |
|
|
|
|
Psychiatric/Psychological:
Psychiatric/Psychological visits may be considered medically necessary when reported with a diagnosis of TMJ.
The following treatments of TMJ may be considered medically necessary as part of a comprehensive pain management plan:
Services not meeting the criteria indicated in this policy will be considered not medically necessary.
90875 |
90876 |
90901 |
97124 |
97129 |
97130 |
|
Mechanical:
Any method to alter occlusion of the teeth is considered a mechanical approach. Frequently, an intraoral appliance will be prescribed. The intraoral appliance (D7880) is excluded from coverage under the medical-surgical programs. Whether performed by a dentist or physician, this approach to the treatment of TMJ dysfunction is not eligible for reimbursement.
The jaw motion rehabilitation system, a manual, hand-held, single individual use device that is U.S Federal and Drug Administration approved, may be considered medically necessary.
21085 |
21110 |
E1700 |
E1701 |
E1702 |
D7880 |
|
The following services are considered not medically necessary:
|
97799 |
97112 |
|
|
|
|
|
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.
Refer to Medical Policy E-1, Durable Medical Equipment, for additional information.
Refer to Medical Policy Y-1, Physical Medicine, for additional information.
Refer to Medical Policy Z-7, Electrical Nerve Stimulation, for additional information.
Covered Diagnosis Codes for 29800, 29804, 21010, 21073, 21089, 21480, 21485, 21490, 70488
M26.601 |
M26.602 |
M26.603 |
M26.611 |
M26.612 |
M26.613 |
M26.621 |
M26.622 |
M26.623 |
M26.631 |
M26.632 |
M26.633 |
M26.641 |
M26.642 |
M26.643 |
M26.69 |
|
|
|
|
|
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.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
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.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
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.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
