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Medical Policy Implementation: Temporomandibular Joint Dysfunction

Effective February 15, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for temporomandibular joint (TMJ) dysfunction.

According to the guidelines of our medical policy, Temporomandibular Joint Dysfunction:

  • The following diagnostic procedures are considered medically necessary in the diagnosis of TMJ dysfunction: diagnostic x-ray, tomograms, and arthrograms; computed tomography (CT) scan or magnetic resonance imaging (MRI); cephalograms; pantograms.
     
  • The following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction: electromyography (including surface EMG); kinesiography; thermography; neuromuscular junction testing; somatosensory testing; transcranial or lateral skull x-rays; intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJ dysfunction); muscle testing; standard dental radiographic procedures; range of motion measurements; computerized mandibular scan; ultrasound imaging/sonogram; arthroscopy for purely diagnostic purposes; joint vibration analysis.
     
  • The following nonsurgical treatments are considered medically necessary in the treatment of TMJ dysfunction: intra-oral removable prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment); pharmacologic treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications).
     
  • The following nonsurgical treatments are considered investigational in the treatment of TMJ dysfunction: electrogalvanic stimulation; Iontophoresis; biofeedback; ultrasound; devices promoted to maintain joint range of motion and to develop muscles involved in jaw function; orthodontic services; dental restorations/prostheses; transcutaneous electrical nerve stimulation (TENS); percutaneous electrical nerve stimulation (PENS); acupuncture; hyaluronic acid.
     
  • The following surgical treatments are considered medically necessary in the treatment of TMJ dysfunction: arthrocentesis; manipulation for reduction of fracture or dislocation of the TMJ; arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment; open surgical procedures (when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed conservative treatment) including, but not limited to arthroplasties; condylectomies; meniscus or disc plication and disc removal.

We strongly encourage you to review this entire policy in our online Medical Policy Manual.

Based on the guidelines of our medical policy, Temporomandibular Joint Dysfunction, AND the submitted diagnosis code(s):

  • CPT® Codes 29800, 64580, 64553, 64568, 64569, 64570, 64555, 64561, 64575, 64581, 90875, 90876, 95867, 95868, 95927, 95937, 96000, 96001, 96002, 96003, 96004 and/or HCPCS Codes A4595, E0720, E0730, S3900 submitted on claims for services provided on and after February 15, 2016 may be denied as investigational services based on the submitted diagnosis codes.
     
  • Claims for services provided on and after February 15, 2016 that include CPT code 21073 and certain diagnosis codes may pend while information to determine medical appropriateness is requested and reviewed. Following this review, CPT code 21073 may be denied as investigational or not medically necessary.
     
  • CPT code 64565 submitted on claims for services provided on and after February 15, 2016 may be denied as an investigational service based on the submitted diagnosis code(s).
     
    Claims for services provided on and after February 15, 2016 that include CPT code 64565 and certain diagnosis codes may pend while information to determine medical appropriateness is requested and reviewed. Following our review, this service may be denied as either an investigational or not medically necessary service.
     
  • CPT codes 64585, 64590, 64595, or 90901 submitted on claims for services provided on and after February 15, 2016 may be denied as investigational services based on the submitted diagnosis code(s).

    Claims for services provided on and after February 15, 2016 that include CPT code 64585, 64590, 64595, or 90901 and certain diagnosis codes may pend while information to determine medical appropriateness is requested and reviewed. Following our review, these services may be denied as investigational.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 15, 2016.

CPT® is a registered mark of the American Medical Association.

Published on: November 16, 2015, 08:00 a.m. ET
Last updated on: November 24, 2020, 23:48 p.m. ET