Temporomandibular Joint (TMJ) Treatments Form

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Temporomandibular Joint (TMJ) Treatments Medical Guideline

Service: Temporomandibular Joint (TMJ) Treatments

PUM 250-0066-2506

Medical Guideline Committee Approval Q2-06/2025 Effective Date 01/01/2026

Related Medical Guidelines:

• Article for Temporomandibular Joint (TMJ) Treatments • General Durable Medical Equipment (DME) Medical Guideline

Coverage for the treatment of temporomandibular joint (TMJ) disorder varies across plans. Refer to the member’s benefit plan document for coverage details.

Description:

Temporomandibular joint (TMJ), Temporomandibular disorder (TMD) causes pain in the jaw joint or in the muscles that move the jaw.

Indications of Coverage:

A. Diagnostic procedures and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders are covered when all of the following apply:

1. The condition is caused by congenital (a physical abnormality present at birth), developmental or acquired deformity, disease or injury. Acquired deformity is a change in the normal shape or size of a body part that happens after birth, as opposed to being present at birth (congenital). These deformities can result from injuries, infections, arthritis, tumors, or other conditions. Examples include misaligned broken bones, deformities due to rheumatoid arthritis, or deformities resulting from conditions like cancer or thyroid disease.
2. There is clearly demonstrated radiographic evidence of significant joint abnormality.
3. The procedure or device is medically necessary for the diagnosis or treatment of the condition (under the accepted standards of the profession of the health care practitioner providing the service).
4. The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.

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5. Elective orthodontic care, periodontic care or general dental care are not address in the medical guideline.

   Benefits for surgical services include arthrocentesis, arthroscopy, arthroplasty, arthrotomy and open or closed reduction of dislocations.

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

   B. In general, the least invasive appropriate surgical treatments should be attempted prior to progression to more complicated surgeries. Nonsurgical management includes three to six months of the following where appropriate:

6. Professional physical therapy is considered a medically necessary conservative method of TMD/TMJ treatment. Therapy may include repetitive active or passive jaw exercises, thermal modalities, manipulation, etc. Please refer to Physical, Occupational and Speech Therapy Medical Guideline for covered services and limitations. A total of four physical or occupational therapy visits related to TMJ condition must be done by a therapist.

7. Pharmacological therapy (Nonsteroidal anti-inflammatory drugs [NSAID’s], opiates, muscle relaxants and low-dose antidepressants may be useful for symptom management).

8. Behavioral therapy such as cognitive behavioral therapy or relaxation therapy.

9. Manipulation for reduction of dislocation or fracture of the TMJ.

10. Trigger Point injection for TMJ pain. Verify plan benefit description for details.
    WPS considers trigger point injections medically necessary for members with temporomandibular pain. For acute pain, generally 2 visits per week for 2 weeks are considered medically necessary. Additional treatment is considered medically necessary when pain persists, and further improvement is expected.

11. Intra-articular corticosteroid injections are considered medically necessary for the treatment of TMJ disorder.

12. Intra-oral appliances, unless the member is unable to open mouth wide enough.

    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

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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 medical necessity. More than 4 adjustments or adjustments that are done more than 1 year after placement of the initial appliance is subject to review to determine medical necessity. One TMJ appliance is considered medically necessary 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.

C. All requests for surgery must include documentation that all medically appropriate non-surgical therapies noted above have been exhausted.

1. Arthrocentesis for TMJ internal derangement is defined as the insertion of two separate single- needle portals or a single double needle portal for input and output of fluids. The process includes insufflation of the joint space, lavage, manipulation of the mandible for the purpose of lysis of adhesions, and the elective infusion of steroids. Arthrocentesis is considered medically necessary when one of the following criteria met:

   a. When imaging and clinical examination demonstrate anchored disc phenomenon; or anterior disc displacement without reduction and without effusion, or osteoarthritis without fibrosis or loose bone particles, or open lock, or hemarthrosis, or b. Pain persists despite at least six months of noninvasive therapies, or c. The presence of hypomobility of the temporomandibular joint and symptoms persist despite at least six months of noninvasive therapy.

2. Therapeutic arthroscopy is considered medically necessary when MRI or other imaging confirms the presence of adhesions, fibrosis, degenerative joint disease, or internal derangement of the disc that requires internal modification.

3. Open surgical procedures including, but not limited to, meniscus or disc repositioning or plication, disc repair, and disc removal with or without replacement are considered medically necessary when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed non- surgical management.

4. Arthroplasty or arthrotomy:

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a. Would include one of the following procedures:

1) Disk repair procedures. 2) Discectomy with or without replacement. 3) Articular surface recontouring (condylectomy and eminectomy or eminoplasty).

b. Arthroplasty or arthrotomy is considered medically necessary when MRI or other imaging confirms the presence of any of the following:

1) Osteoarthritis or osteoarthrosis; or 2) Severe disc displacement associated with degenerative changes or perforation; or 3) Scarring that is severe and often the result of old injury or prior procedure.

5. Joint replacement with an FDA approved prosthesis (e.g., TMJ Concepts prosthesis, the Christensen TMJ Fossa-Eminence Prosthesis System-partial TMJ prosthesis, the Christensen TMJ Fossa-Eminence/Condylar Prosthesis System- Christensen total joint prosthesis, or the W. Lorenz TMJ prosthesis) is considered medically necessary when used as a salvage device for treatment of end stage TMJ disease, when conservative management and other surgical treatment has been unsuccessful, and MRI or other imaging documents one or more of the following:

   a. Temporal bone that no longer provides a smooth articular fossa; or b. Damaged condyles that are no longer ball-shaped; or c. Persistent, stable inflammatory arthritis that is not responsive to other modalities of treatment; or d. Recurrent fibrous or bony ankylosis that is not responsive to other modalities of treatment; or e. Loss of mandibular condylar height and/or occlusal relationship due to trauma, resorption, pathological lesion, or congenital anomaly; or f. Failed autologous bone graft or alloplastic reconstruction effort.

6. Autogenous grafts (e.g., costochondral, cartilage, dermal, fat, fascial, and other autogenous graft materials) may be considered medically necessary upon individual case review. Autologous costochondral grafts are considered medically necessary when criteria for joint replacement (see above) are met or when there is congenital absence or deformity of the joint or for surgical reconstruction post head and neck tumor resection.

7. In certain cases (e.g., bony ankylosis and failed TMJ total joint prosthetic implants) that require immediate surgical intervention, surgery may be considered

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medically necessary without prior non-surgical management.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Intra-oral appliances for the treatment of headache or trigeminal neuralgia are considered experimental, investigational, or unproven as there is insufficient data on the effectiveness of this therapy.

E. Elective orthodontic care, periodontic care, or general dental care are not addressed in this medical guideline.

F. Appliances for bruxism (teeth grinding or clenching), are not addressed in this medical guideline.

G. The following are considered experimental and investigational for diagnosis and treatment of TMJ disorders:

Diagnostic procedures: a. Artificial intelligence technologies for the diagnosis of TM Cephalometric or lateral skull x-rays b. Computerized mandibular scan/kinesiography/electrogathograph/jaw tracking c. Diagnostic study models d. Electromyography (EMG), surface EMG e. Electronic registration (Myomonitor) f. Genetic testing g. Joint vibration analysis h. Kinesiography i. Measurements of circulating omentin-1 levels j. Muscle testing/range of motion measurements (incidental to examination)

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k. Neuromuscular junction testing l. Salivary stress biomarkers (e.g., alpha-amylase and cortisol levels) m. Somatosensory testing n. Sonogram (ultrasonic Doppler auscultation) o. Standard dental radiographic procedures p. Thermography q. Ultrasonography

Non-surgical treatments: a. Autologous blood injection b. Biofeedback c. Bio-oxidative ozone therapy d. Botulinum toxin (type A or type B)
e. Continuous passive motion cranial (craniosacral) manipulation f. Cranio (craniosacral) manipulation g. Cryo-analgesia h. Dental restorations/prostheses i. Dextrose prolotherapy j. Diathermy, infrared, and ultrasound treatments k. Dry needling l. Gallium aluminum arsenide laser therapy for the treatment of TMD with myofascial pain m. Hydrotherapy (immersion therapy, whirlpool baths) n. Hypnosis/relaxation therapy o. Injection of plasma rich in growth factors p. Intra-articular injection of analgesics q. Intra-articular injection of hyaluronic acid (viscosupplementation) r. Intra-articular injection of platelet-rich plasma s. Intra-articular injections of rituximab t. Intra-oral appliances for headache or trigeminal neuralgia u. Intra-oral, reversible prosthetic appliance for all other indications v. Iontophoresis w. Irreversible occlusion therapy aimed at modification of the occlusion itself through alteration of the tooth structure or jaw position x. Ketamine (local/intra-articular administration) y. Laser capsulorrhaphy z. Low level (cold) laser myofunctional therapy aa. Low-load prolonged-duration stretch (LLPS) devices bb. Magnetic neurostimulator cc. Manual therapy dd. MIRO therapy ee. Myofunctional therapy ff. Myomonitor treatment (e.g., J-4, J-5, BNS-40, Bio-TENS) gg. Neuromuscular reeducation hh. Orthodontic/bite adjustment services and orthodontic fixed appliances

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ii. Passive rehabilitation therapy jj. Permanent mandibular repositioning (e.g., equilibration, orthodontics) kk. Photo-biomodulation for the treatment of TMD and TMJ dysfunction ll. Phototherapy (e.g., low-level (cold) laser therapy (LLLT) and light- emitting diode (LED) therapy) mm. Platelet-rich fibrin for the treatment of TMD and TMJ dysfunction nn. Prophylactic management of TMJ disorder, including occlusal adjustment oo. Propranolol pp. Radiofrequency generator thermolysis qq. Sclerotherapy rr. Stem Cell therapy ss. Therabite Jaw Motion Rehabilitation System tt. Transcranial direct current stimulation uu. Transcutaneous electrical nerve stimulation (TENS)

Surgical treatments: a. Orthognathic surgery b. Treatment of alveolar cavitational osteopathosis c. Permanent mandibular repositioning (e.g., full mouth reconstruction) d. Dental implants e. Dental restorations f. Extraction of wisdom teeth g. Orthodontic services h. TMJ arthroplasty implants that are not FDA approved.

Documentation Required:

• 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.

Disclaimer: This guideline 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 guideline. 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 guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines 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 guideline 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,

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investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and 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 for someone without a health condition. The equipment is primarily intended for use in the member’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 guideline.

Guideline Review History:

Implemented 01/01/26 Medical Guideline Committee Approval 06/26/25 Reviewed

06/26/25 Developed 06/26/25

Approved by the Medical Director

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

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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 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

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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

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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)

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70542 WITH CONTRAST MATERIAL(S) 70543 WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) 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)

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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)

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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

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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 E1700 JAW MOTION REHABILITATION SYSTEM E1701 REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PACKAGE OF 6 E1702 REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PACKAGE OF 200