Anthem Blue Cross Connecticut CG-SURG-09 Temporomandibular Disorders Form

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.

Clinical Indications

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.