Temporomandibular Joint (TMJ) Treatments Article Form

Policy Article for Temporomandibular Joint (TMJ) Treatments Medical Policy

Article # A250-0066-2506 Coverage for the treatment of temporomandibular joint (TMJ) disorder varies across plans.
Refer to the member’s benefit plan document for coverage details. TMJ services are not a covered benefit under the WI Mandate for Medicare supplement plans. Durable Medical Equipment DME is only considered “durable” if it is prescribed by a qualified healthcare provider for a medical reason and is not typically useful to someone without a health condition. The equipment is primarily intended for use in the patient’s home.

Description/Definitions:
Arthrocentesis, also known as joint aspiration, is a minimally invasive surgical procedure performed to drain fluid from a joint capsule. Arthrography-a type of imaging used to evaluate and diagnose unexplained pain and joint conditions.
Arthroplasty-surgery to relieve pain and restore range of motion by realigning or reconstructing a joint. Arthroscopy-a surgical procedure used to visualize, diagnose, and treat problems inside a joint. Arthrotomy-surgical exploration of a joint, including inspecting the cartilage, intra-articular structures, joint capsule, and ligaments. Bruxism-clenching or grinding of the teeth. Temporomandibular joint (TMJ), Temporomandibular disorder (TMD) causes pain in the jaw joint or in the muscles that move the jaw.
There is no widely accepted standard test to diagnose TMD. In the majority of cases, the patient’s history, signs and symptoms, combined with a physical examination of the face and jaw, provide sufficient information to diagnose these disorders. Routine x-rays may be used to identify underlying osteoarthritis or other bony abnormalities of the TMJ. Arthrography, magnetic resonance imaging (MRI) and computed tomography (CT) are generally not indicated,

although selected studies may be appropriate for persistent TMD when clinical examination indicates the presence of internal derangement and surgery is being considered. Noninvasive Treatment, reversible therapies are used in the initial treatment of symptomatic TMD. In many cases, TMD is self-limiting and often responds to simple measures such as eating soft foods, applying heat or ice, and avoiding extreme jaw movements (e.g., wide yawning, gum chewing).

Other conservative treatments may include: • Pharmacological pain control • Physical therapy • Intra-oral appliances Surgery is only considered if there is persistent pain and functional limitations in patients with structural anatomic pathology or TMJ intraarticular disorders that do not respond to a reasonable course of nonsurgical interventions.

WI state mandate: TMJ Disorders Health insurance providing coverage of any diagnostic or surgical procedure involving a bone, joint, muscle, or tissue is required to provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for the correction of temporomandibular (TMJ) disorders. The condition is caused by congenital, developmental or acquired deformity, disease or injury. Coverage may be subject to any exclusions and limitations, deductibles, copayments, coinsurance, and out-of-pocket expenses that generally apply to other conditions covered by the plan. Coverage may include intraoral splint therapy devices but is not required to include cosmetic or elective orthodontic, periodontic, or general dental care. Plans can have prior authorization requirements on surgical or nonsurgical TMJ services. [s. 632.895 (11), Wis. Stat.]. This mandate does not apply to a Medicare supplement policy.
Benefits are not available for cosmetic or elective orthodontic care, periodontic care or general dental care.

Non-surgical treatment including clinical examinations, oral appliances (orthotic splints), arthrocentesis and trigger-point injections.

In general, the least invasive appropriate surgical treatments should be attempted prior to progression to more complicated surgeries. Prolonged (greater than 6 months) application of TMD/J intra-oral appliances is not considered medically necessary unless, upon individual case review, documentation is provided that supports prolonged intra-oral appliance use. Treatment of customized (standard) TMJ splint required with documentation of prolonged trial (1 year) of use required supporting failure /or contraindication of trial.

Adjustments of intra-oral appliances performed within 6 months of initial appliance therapy are considered medically necessary; while adjustments performed after 6 months are subject to review to determine necessity and appropriateness. More than 4 adjustments or adjustments that are done more than 1 year after placement of the initial appliance is subject to review. One TMJ appliance every 2 years. Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and effectiveness are not eligible for coverage. Replacement or repair is subject to review to determine necessity and appropriateness.
Replacement of a lost, missing or stolen intra-oral appliance is not covered.

All requests for surgery must include documentation that all medically appropriate non-surgical therapies noted above have been exhausted. There are no benefits for appliances for bruxism (teeth grinding or clenching), they are excluded from coverage as they are not considered treatment of an illness or injury.

Documentation Requirements: • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the item/service that meets all the coding guidelines.

All requests for TMJ surgery must include a detailed history of the condition, diagnostic imaging results and documentation of prior medical and surgical treatment.

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven under the terms of the clinical guidelines will not be covered. Durable Medical Equipment DME is only considered “durable” if it is prescribed by a qualified healthcare provider for a medical reason and is not typically useful to someone without a health condition. The equipment is primarily intended for use in the patient’s home.
TMJ treatments are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.
State mandates, laws or benchmark supersede this medical policy. Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Codes
Code Description

20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S) 20553 SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES 20560 NEEDLE INSERTION(S) WITHOUT INJECTION(S); 1 OR 2 MUSCLE(S) 20561 3 OR MORE MUSCLES 20605 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (E.G., TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW, OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE 20606 ARTHROCENTESIS, ASPIRATION AND /OR INJECTION, INTERMEDIATE JOINT OR BURSA (E.G., TEMPOROMANDIBULAR, ACROMIOCLAVICULAR,

WRIST, ELBOW, OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING 20910 CARTILAGE GRAFT; COSTOCHONDRAL [AUTOLOGOUS] 21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT 21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 21060 MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 21070 CORONOIDECTOMY (SEPARATE PROCEDURE) 21073 MANIPULATION OF TEMPOROMANDIBULAR JOINT(S), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICE (I.E., GENERAL OR MONITORED ANESTHESIA CARE) 21076 IMPRESSON AND CUSTOM PREPARATION; SURGICAL OBTURATOR PROSTHEIS 21079 INTERIM OBTURATOR PROSTHESIS 21080 DEFINITIVE OBTURATOR PROSTHESIS 21081 MANDIBULAR RESECTION PROSTHESIS 21085 ORAL SURGICAL SPLINT 21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL 21120-21123 GENIOPLASTY 21125-21127 AUGMENTATION MANDIBULAR BODY OR ANGLE 21141-21147 RECONSTRUCTION MIDFACE, LEFORT I 21150-21151 RECONSTRUCTION MIDFACE, LEFORT II 21154-21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21159-21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (E.G., MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C OR L OSTEOTOMY; WITHOUT BONE GRAFT 21194 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL , VERTICAL, C OR L OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) 21195-21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT 21198 OSTEOTOMY, MANDIBLE, SEGMENTAL;
21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT

21206 OSTEOTOMY, MAXILLA, SEGMENTAL (E.G., WASSMUND OR SCHUCHARD) 21208-21209 OSTEOPLASTY, FACIAL BONES 21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT) 21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT 21243 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT 21247 RECONSTRUCTION OF MANDIBULAR CONDYL WITH BONE AND CARDILAGE AUTOGRAFTS (INCLUDE OBTAINING GRAFTS) (E.G., FOR HEMIFACIAL MICROSOMIA) 21248-21249 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (E.G., BLADE, CYLINDER) 21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS) 21440 CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21445 OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21450 CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITHOUT MANIPULATION 21451 WITH MANIPULATION 21452 PERCUTANEOUS TREATMENT OF MANDIBULAR FRACTURE; WITH EXTERNAL FIXXATION 21453 CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION 21454 OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION 21461 OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION 21462 WITH INTERDENTAL FIXATION 21465 OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE 21470 OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS 21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21485 COMPLICATED (E.G., RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT 21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION

21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 29800 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) 29804 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL 38205 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION, PER COLLECTION; ALLOGENIC
38206 AUTOLOGOUS 38220 DIAGNOSTIC BONE MARROW; ASPIRATION(S) [INTRA-ARTICULAR INJECTION] 38230 BONE MARROW HARVESTING FOR TRANSPLANTATION; ALLOGENIC 38232 AUTOLOGOUS 38240 HEMATOPOIETIC PROGENITOR CELL (HPC); ALLOGENEIC TRANSPLANTATION PER DONOR 38241 AUTOLOGOUS TRANSPLANTATION 38242 ALLOGENEIC LYMPHOCYTE INFUSIONS 70300 RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW 70310 PARTIAL EXAMINATION, LESS THAN FULL MOUTH 70320 COMPLETE, FULL MOUTH 70328 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; UNILATERAL
70330 BILATERAL
70332 TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 70336 MAGNETIC RESONANCE (E.G., PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)
70355 ORTHOPANTOGRAM (E.G., PANORAMIC X-RAY) 70486 COMPUTERIZED TOMOGRAPHY, MAIXLLOFACIAL AREA; WITHOUT CONTRAST MATERIAL 70487 COMPUTERIZED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) 70488 WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 70540 MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S) 70542 WITH CONTRAST MATERIAL(S) 70543 WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S0 AND FURTHER SEQUENCES

76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (E.G., THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION [ULTRASONOGRAPHY OF TEMPORMANDIBULAR JOINTS] 77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) [JOINT VIBRATION ANALYSIS FOR TMJ] 90832-90840 PSYCHOTHERAPY 90867 THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; INITIAL, INCLUDING CORTICAL MAPPING, MOTOR THRESHOLD DETERMINATION, DELIVERY AND MANAGEMENT 90868 SUBSEQUENT DELIVERY AND MANAGEMENT, PER SESSION 90869 SUBSEQUENT MOTOR THRESHOLD RE-DETERMINATION WITH DELIVERY AND MANAGEMENT 90880 HYPNOTHERAPY 90901 BIOFEEDBACK TRAINING BY ANY MODALITY 95867 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNLATERAL 95868 CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL 95887 NEEDLE ELECTROMYOGRAPHY, NON-EXTREMITY (CRANIAL NERVE SUPPLIED OR AXIAL) MUSCLE(S) DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 95937 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY ONE METHOD 96900 ACTINOTHERAPY (ULTRAVIOLET LIGHT) 96910 PHOTOCHEMOTHERAPY; TAR AND ULTRAVIOLET B (GOECKERMAN TREATMENT) OR PETROLATUM AND ULTRAVIOLET B 96912 PHOTOCHEMOTHERAPY; PSORALENS AND ULTRAVIOLET A (PUVA) 96913 PHOTOCHEMOTHERAPY (GOECHERMAN AND /OR PUVA) FOR SEVERE PHOTORESPONSIVE DERMATOSES REQUIRING AT LEAST 4-8 HOURS OF CARE UNDER DIRECT SUPERVISION OF THE PHYSICIAN (INCLUDES APPLICATION OF MEDICATION AND DRESSINGS) 97010 APPLICATION OF A MODALITY BY 1 OR MORE AREAS; HOT OR COLD PACKS 97014 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 97024 DIATHERMY (E.G., MICROWAVE) 97026 INFRARED 97028 ULTRAVIOLET 97032 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES

97033 IONTOPHORESIS, EACH 15 MINUTES 97035 ULTRASOUND, EACH 15 MINUTES 97036 HUBBARD TANK, EACH 15 MINUTES 97110 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97124 MASSAGE, INCLUDING EFFLUERAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) 97129 THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (E.G., ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (E.G., MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES +97130 EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 97140 MANUAL THERAPY TECHNIQUES (E.G., MOBILIZATION/MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES 97350 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT (E.G., MUSCULOSKELTAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES 97810 ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT +97811 WITHOUT ELECTRICAL STIMULATION, EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT, WITH RE- INSERTION OF NEEDLE(S) (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) 97813 WITH ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT +97814 WITH ELECTRICAL STIMULATION, EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT, WITH RE- INSERTION OF NEEDLE(S) (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) 0232T INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED

0481T INJECTION(S), AUTOLOGOUS WHITE BLOOD CELL CONCENTRATE (AUTOLOGOUS PROTEIN SOLUTION), ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION, WHEN PERFORMED D0320 TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTION D0321 OTHER TEMPOROMANDIBULAR JOINT FILMS, BY REPORT D0322 TOMOGRAPHIC SURVEY D0330 PANORAMIC RADIOGRAPHIC IMAGE D0340 CEPHALOMETRIC FILM D0701 PANORAMIC RADIOGRAPHIC IMAGE-IMAGE CAPTURE ONLY D0702 2-D CEPHALOMETRIC RADIOGRAPHIC IMAGE-IMAGE CAPTURE ONLY D5110- D5800 PROSTHODONTICS (REMOVABLE) D5931- D5933, D5936 OBTURATOR PROSTHESES D5934 MANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGE D5982 SURGICAL STENT D5988 SURGICAL SPLINT D6210- D6999 PROSTHODONTICS (FIXED) D7630 MANDIBLE, OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) D7640 MANDIBLE, CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) D7730 MANDIBLE, OPEN REDUCTION D7740 MANDIBLE, CLOSED REDUCTION D7810- D7880 REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS D7881 OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT D7899 UNSPECIFIED TMD THERAPY, BY REPORT D7940 OSTEOPLASTY, FOR ORTHOGNATHIC DEFORMITIES D7941 OSTEOTOMY-MANDIBULAR RAMI D7943 OSTEOTOMY-MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT D7944 OSTEOTOMY-SEGMENTED OR SUBAPICAL D7945 OSTEOTOMY, BODY OF MANDIBLE D7946 LEFORT I (MAXILLA, TOTAL) D7947 LEFORT I (MAXILLA, SEGMENTED) D7948 LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION), WITHOUT BONE GRAFT

D7950 OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA, AUTOGENOUS OR NONAUTOGENOUS, BY REPORT D7951 SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES D7953 BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION-PER SITE D7955 REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT D7993 SURGICAL PLACEMENT OF CRANIOFACIAL IMPLANT-EXTRA ORAL D9130 TEMPOROMANDIBULAR JOINT DYSFUNCTION-NON-INVASIVE PHYSICAL THERAPIES D9943- D9946 OCCLUSAL GUARD D9951- D9952 OCCLUSAL ADJUSTMENT, LIMITED/COMPLETE E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, 2 LEAD, LOCALIZED STIMULATION E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, 4 OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT E0746 ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE