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Medical Policy Update: Temporomandibular Joint Dysfunction

Effective January 14, 2020, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Temporomandibular Joint Dysfunction.

Access our Medical Policy Manual to review this medical policy content.¹


Claims submitted for services provided on and after January 14, 2020 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be processed as follows.

  • Regardless of the submitted diagnosis, the services represented by CPT® codes 90875 and 90876 will be denied as not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.

  • Based on the submitted diagnosis code(s), the services represented by CPT code 90901 may be denied as experimental/investigational non-covered services.

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT code 90901. Following our review of medical record information, these services may be denied as not medically necessary.

  • The services represented by CPT codes 95867, 95868 and 95927 will be excluded from the guidelines of this policy. These codes will be processed based solely on member benefits.

  • Regardless of the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by HCPCS codes J7323, J7324, J7325 or J7327. Following our review of medical record information, these services may be denied as not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after January 14, 2020.

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

¹The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: December 12, 2019, 00:42 a.m. ET
Last updated on: December 12, 2019, 16:24 p.m. ET