Clinical UM Guideline

This document addresses treatments for conditions of the temporomandibular joint (TMJ) and related musculoskeletal structures. Such conditions are commonly referred to as temporomandibular disorders (TMD), temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, or craniomandibular disorder (CMD).

Note: Please refer to the following documents for additional information on related topics:

• CG-ANC-03 Acupuncture
• CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
• CG-MED-28 Iontophoresis
• CG-MED-65 Manipulation Under Anesthesia
• CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• MED.00002 Selected Sleep Testing Services
• SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

Note:

• Pharmacologic therapy (that is, analgesics, anti-inflammatory drugs, and muscle relaxants) and therapeutic injections may be addressed in related pharmacy guidelines. 
• See the applicable guidelines in use by the member’s health plan for criteria addressing behavioral health and physical therapy services used to treat temporomandibular disorders.

Medically Necessary:

Intraoral appliances (for example, occlusal splints, bite appliances, and mandibular occlusal repositioning appliances) are considered medically necessary for temporomandibular disorders.

Surgical procedures are considered medically necessary for the treatment of temporomandibular disorders when the following criteria are met (A and B):

1. Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by the following:
   1. Radiographic documentation of temporomandibular joint pathology (for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors); and
   2. For individuals age under the age of 18: documentation of completion of skeletal growth by either:
      1. Long bone x-ray; or
      2. Serial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;
         and
2. Either of the following:
   1. Temporomandibular joint pain is due to a maxillary or mandibular skeletal deformity; or
   2. The individual has a clinically significant functional impairment refractory to at least 6 months of non-surgical treatment.

Not Medically Necessary:

The following nonsurgical treatments are considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

1. Electrogalvanic stimulation (EGS); or
2. Jaw motion rehabilitation systems; or
3. Mandibular image-guided rehabilitative orthopedics (also known as MIRO Therapy^®); or
4. Occlusal equilibration, bite adjustment, irreversible occlusion therapy.

Surgical procedures for temporomandibular disorders are considered not medically necessary when the above criteria are not met.

The following diagnostic tests and procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

1. Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning); or
2. Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning); or
3. Electromyography (including percutaneous or surface electrode methods); or
4. Kinesiography; or
5. Laryngeal function studies; or
6. Rhinomanometry; or
7. Somatosensory testing/neuromuscular junction testing; or
8. Swallowing studies or tests; or
9. Thermography.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

When services are also Not Medically Necessary:
For the diagnosis codes listed above for TMD and related diagnoses, for the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Temporomandibular disorders (TMD) is a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndromes, and craniomandibular disorder (CMD), that includes a variety of medical and dental conditions involving the masticatory muscles and the temporomandibular joint, as well as contiguous tissue components. The prevalence of TMJD is in the range of 5 to 12% (NIDCR, 2018). The incidence is higher in younger individuals and in women. Although some cases can be linked to physical trauma or disease conditions, in most cases the cause is unknown.

The most frequent presenting symptom associated with TMD is pain, usually localized to the muscles of mastication, the preauricular area, and/or the TMJ. This pain may be related to trauma, (such as a blow to the face), inflammatory or degenerative arthritis, or may be due to the mandible being pushed back towards the ears whenever the individual chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening the mouth normally. Other common complaints reported by individuals include earache, headache, and facial pain. Individuals may also have limited or asymmetric jaw movement and joint sounds that are usually described as clicking, popping, grating, or crepitus in the TMJ.

Most cases of TMD can be treated without surgery. Treatments may include behavioral changes, physical therapy, pharmacologic therapy (e.g., oral medications for pain, anti-inflammatory injections), and reversible, removable, intraoral dental splints (also called occlusal orthotics or occlusal splints). Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. Such procedures include but are not limited to the following:

• Arthrocentesis
• Arthroplasty
• Arthroscopic surgery
• Condylectomy
• Disc or meniscus plication
• Disc removal
• Manipulation for reduction of fracture or dislocation
• Modified condylotomy
• Prosthetic implantation

There are no criteria to identify people who would most likely benefit from surgery. A review of available published evidence regarding the safety and efficacy of various medical and surgical treatment modalities for TMJ revealed inconsistent methodologies in study design and  clinical outcome measurements (Al-Moraissi, 2017; Bouchard, 2017; Nandhini, 2018; Schiffman, 2007; Tatli, 2017; Truelove, 2006; Zhang, 2020).

In 2014, Schiffman and colleagues found that, although the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been reliable, they were below the target sensitivity of greater than or equal to 0.70 and specificity of greater than or equal to 0.95. This empirical finding prompted a revision. The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I include both a valid screening protocol for detecting any pain-related TMD, as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity greater than or equal to 0.86, specificity greater than or equal to 0.98). The authors stated:

TMD is the second most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability… Taken together, a new dual-axis Diagnostic Criteria for TMD (DC/TMD) will provide evidence-based criteria for the clinician to use when assessing patients, and will facilitate communication regarding consultations, referrals, and prognosis.

In 2017, the American Academy of Oral and Maxillofacial Surgeons (AAOMS) issued Parameters of Care (6^th edition) which stated the following:

Temporomandibular joint (TMJ) surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection…Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient.

The National Institute of Dental and Craniofacial Research (2023) states the following on temporomandibular joint and muscle disorders:

Open surgery gives access to the temporomandibular joint through a cut (incision) next to the ear. It’s important to know that surgery makes permanent changes to your joint. There are no long-term research studies on the safety of open surgery for TMDs or on how well it works to relieve symptoms.

Surgery should only be considered if:

• There is destruction of the joint that cannot be fixed with other procedures.
• There are severe symptoms (pain and/or difficulty opening the mouth), despite trying other treatments.

Several devices have obtained pre-market approval or clearance from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD. The FDA-approved labeling for these devices has similar indications. However, the published evidence evaluating clinical outcomes of these devices is limited and clinical utility has not been empirically established.

Analgesics: Medications that provide pain relief.

Arthroplasty: Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.

Craniomandibular disorder (CMD): A dental term used to describe diseases or disorders of the muscles of the head and neck, with special reference to the masticatory (chewing) muscles.

Disc: Shortened terminology for an intervertebral disc or a TMJ disc; a disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones.

Mandible: Bone of the lower jaw.

Meniscus: A cartilage pad between the two joint surfaces within the TMJ, acting as a smooth surface for the joint to move on.

Modified condylotomy: An extra-articular surgical procedure used to manage TMJ dysfunction. The primary purpose of the procedure is to increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence.

Occlusal orthotic device: A dental term used to describe a reversible, removable intraoral appliance, such as a splint.

Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.

Temporal bone: A large, irregular bone situated at the base and side of the skull; connected with the mandible via the TMJ.

Temporomandibular joint (TMJ): Joint that hinges the mandible to the temporal bone of the skull; one of the most frequently used joints in the entire body, moving whenever a person eats, drinks, or talks.

Peer Reviewed Publications:

1. Al-Moraissi EA, Wolford LM, Perez D, et al. Does orthognathic surgery cause or cure temporomandibular disorders? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(9):1835-1847.
2. Bouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular lavage versus nonsurgical treatments for temporomandibular disorders: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(7):1352-1362.
3. Bouloux GF. Modified condylotomy for temporomandibular joint dysfunction. Atlas Oral Maxillofac Surg Clin North Am. 2011; 19(2):169-175.
4. Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: A systematic review and meta-analysis. J Am Dent Assoc. 2012; 143(8):847-857.
5. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005; 63(8):1174-1179.
6. Hall HD, Navarro EZ, Gibbs JS. One- and three year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg. 2000; 58(1):7-17.
7. Keller EE, Baltali E, Liang X, et al. Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study. J Oral Maxillofac Surg. 2012; 70(2):276-288.
8. Lindenmeyer A, Sutcliffe P, Eghtessad M, et al. Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review. J Oral Maxillofac Surg. 2010; 68(11):2755-2764.
9. Linsen SS, Reich RH, Teschke M. Mandibular kinematics in patients with alloplastic total temporomandibular joint replacement-a prospective study. J Oral Maxillofac Surg. 2012; 70(9):2057-2064.
10. Manfredini D, Rancitelli D, Ferronato G, Guarda-Nardini L. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil. 2012; 39(4):245-251.
11. Marques FBC, de Lima LS, Oliveira PLE, Magno MB et al. Are temporomandibular disorders associated with facial asymmetry? A systemic review and meta-analysis. Orthod Craniofac Res. 2021; 24(1): 1-16.
12. McLeod NM, Saeed NR, Hensher R. Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis. Br J Oral Maxillofac Surg. 2001; 39(1):63-66.
13. Nandhini J, Ramasamy S, Ramya K, et al. Is nonsurgical management effective in temporomandibular joint disorders? A systematic review and meta-analysis. Dent Res J (Isfahan). 2018; 15(4):231-241.
14. Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007; 86(1):58-63.
15. Tatli U, Benlidayi ME, Ekren O, Salimov F. Comparison of the effectiveness of three different treatment methods for temporomandibular joint disc displacement without reduction. Int J Oral Maxillofac Surg. 2017; 46(5):603-609.
16. Truelove E, Huggins KH, Manci L, Dworkin SF. The efficacy of traditional, low cost, and non-splint therapies for temporomandibular disorder. J Am Den Assoc. 2006; 137(8):1099-1107.
17. Valesan LF, Da-Cas CD, Reus JC, et al. Prevalence of temporomandibular joint disorders: a systematic review and meta-analysis.Clin Oral Investig. 2021; 25(2):441-453.
18. Werther JR, Hall HD, Gibbs JS. Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):668-679.
19. Widmalm S, Brooks S, Sano T, et al. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol. 2006; 35(5):334-338.
20. Wolford LM. Factors to consider in joint prosthesis systems. Proc (Bayl Univ Med Cent). 2006; 19(3):232-238.
21. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of two temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg. 2003a; 61(6):685-690.
22. Wolford LM, Pitta MC, Reiche-Fishel O. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003b; 32(3):268-274.
23. Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(6):671-675.
24. Zhang SH, He KX, Lin CJ, et al. Efficacy of occlusal splints in the treatment of temporomandibular disorders: a systematic review of randomized controlled trials. Acta Odontol Scand. 2020; 78(8):580-589.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Oral and Maxillofacial Surgery (AAOMS). Parameters of care: clinical practice guidelines for oral and maxillofacial surgery. 2017. Available at: https://members.aaoms.org/PersonifyEbusiness/AAOMSStore/Product-Details/productId/1518255. Accessed on September 11, 2023.
2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical condition statements: temporomandibular disorders. 2017. Available at: http://www.aaoms.org/practice-resources/aaoms-advocacy-and-position-statements/clinical-resources. Accessed on September 11, 2023.
3. American Association for Dental Research (AADR). Policy statement: temporomandibular joint disorders (TMJ). Adopted 1996; reaffirmed 2015. Available online at: http://www.aadocr.org/science-policy/temporomandibular-disorders-tmd. Accessed on September 11, 2023.
4. de Souza RF, Lovato da Silva CH, Nasser M, et al. Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012;(4):CD007261.
5. National Institutes National Institute of Dental and Craniofacial Research (NIDCR). 2018a. Prevalence of TMJD and its Signs and Symptoms. Last reviewed July 2018. Available at: https://www.nidcr.nih.gov/research/data-statistics/facial-pain/prevalence. Accessed on September 11, 2023.
6. National Institutes National Institute of Dental and Craniofacial Research (NIDCR). 2023. TMJ (Temporomandibular Joint & Muscle Disorders). Last updated March 2023. Available at: https://www.nidcr.nih.gov/health-info/tmj/more-info. Accessed on September 11, 2023.
7. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network (International Association for Dental Research) and Orofacial Pain Special Interest Group (International Association for the Study of Pain). J Orol Fac Pain Headache. 2014; 28(1):6-27.

Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
MIRO Therapy
Patient-Fitted TMJ Reconstruction Prosthesis
Temporomandibular Joint
TMJ
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis
TMJ Fossa-Eminence Prosthesis System
TMJ Fossa-Eminence Prosthesis System^™
TMJ Patient Specific Fossa-Eminence Prosthesis System^™
Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation).
TMJ Partial Temporomandibular Joint Replacement System,
Total Temporomandibular Joint (TMJ) Replacement System

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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