Humana Commercial Clinical Policy

Humana Temporomandibular Joint Disorders Form


Effective Date

09/28/2023

Last Reviewed

NA

Original Document

  Reference



Description

Temporomandibular joint (TMJ) or temporomandibular disorders (TMD) are collective terms for conditions which cause pain and dysfunction in the masticatory muscles and the jaw joint. These conditions include, but may not be limited to:

  • Arthritis
  • Complications following radiation for head and neck cancer
  • Internal joint derangement
  • Myofascial pain syndrome

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

There are a variety of symptoms that may be linked to TMJ/TMD. The most common symptom is a dull, aching, intermittent pain in the jaw. Other symptoms include, but may not be limited to:

  • Changes in the way the upper and lower teeth fit together
  • Earache and/or headache
  • Jaw muscle stiffness
  • Limited movement (mandibular hypomobility) or locking of the jaw (lockjaw)
  • Painful clicking, popping or grating of the jaw when opening or closing the mouth
  • Radiating pain in or around the eye, ear, jaw, neck or temporal region
  • Spasms that cause the mouth to remain tightly closed (trismus)

Evaluation for TMJ/TMD often begins with physical examination, but may also involve muscle testing, radiographic imaging or range of motion measurements.

There are multiple nonsurgical and surgical treatments available for TMJ/TMD. Nonsurgical options may include medications, physical therapy or removable occlusal orthotic appliance therapy. In an individual with persistent TMJ/TMD symptoms despite nonsurgical management, surgical treatments include, but may not be limited to:

  • Arthrocentesis (joint aspiration) – Minimally invasive procedure that involves inserting a small needle into the joint to irrigate fluid and remove debris
  • Arthroplasty – Restores range of motion by repair or replacement of the joint; replacement involves partial or total grafts or implants. Examples of US Food & Drug Administration (FDA) approved prosthetic joint replacement devices include, but may not be limited to: TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis System, TMJ Fossa-Eminence Prosthesis System and Zimmer Biomet Total Mandibular Joint Replacement System.
  • Arthroscopy – An endoscope is placed inside the joint for diagnostic purposes and/or to remove any inflamed tissue or adjust parts of the jaw that are misaligned
  • Arthrotomy – May encompass a range of surgical procedures including debridement or disc repair, repositioning or replacement

Temporomandibular Joint Disorders Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0346-023 Page: 3 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Condylectomy – Complete removal of jaw condyle
  • Condylotomy – Surgical division the jaw condyle
  • Coronoidectomy – Removal of the anterior part of the upper ramus of the mandible

There are other treatments and devices that are not widely used or generally accepted for the treatment of TMJ/TMD which include, but may not be limited to:

  • Intra-aural devices (eg, TMJ NextGeneration) – Treats the TMJ/TMD pain with an insert placed in the ear canal, which is near the temporomandibular joint (Refer to Coverage Limitations section)
  • Iontophoresis – Uses an electrical current to deliver a medication through the skin or mucosa over the TMJ/TMD (Refer to Coverage Limitations section)
  • Jaw mobility stretching devices (eg, Dynasplint System, OraStretch Press Jaw Motion Rehab System, TheraBite Jaw Motion Rehabilitation System) – Handheld unit designed to stretch or exercise an individual’s jaw (Refer to Coverage Limitations section)

For information regarding proposed evaluation or treatments for TMJ not addressed in this policy, please see the following Medical Coverage Policies:

  • Acupuncture – Refer to Acupuncture Policy
  • Biofeedback – Refer to Biofeedback Policy
  • Chiropractic manipulation/therapy – Refer to Chiropractic Care
  • Dry needling (needle insertion without injection of medication) – Refer to Injections for Chronic Pain Conditions Policy
  • Low level laser therapy (LLLT) (cold laser, photobiomodulation) – Refer to Low Level Laser and High Power Laser Therapy
  • Manipulation under anesthesia – Refer to Manipulation Under Anesthesia Policy

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination|Treatment of TMJ/TMD is generally excluded by certificate. Please consult the member’s individual certificate regarding Plan coverage.

Any state mandates for TMJ/TMD take precedence over this medical coverage policy.

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of TMJ/TMD.

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

EVALUATION

Humana members may be eligible under the Plan for diagnostic testing for TMJ/TMD using the following modalities:

  • Examination including a history, physical examination, muscle testing, range of motion measurements and psychological evaluation as necessary;
  • AND one of the following:
  • Computed tomography (CT) ONLY when performed in conjunction with anticipated surgical management; OR
  • Magnetic resonance imaging (MRI) ONLY when performed in conjunction with anticipated surgical management; OR
  • Radiographic imaging

Temporomandibular Joint Disorders Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0346-023 Page: 5 of 14

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

TREATMENT

Humana members may be eligible under the Plan for the following nonsurgical treatments of TMJ/TMD:

  • Physical therapy when qualifying criteria are met and not excluded by certificate (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); OR
  • Removable occlusal orthotic appliance therapy that maintains current bite or position of the jaw or teeth and is not utilized as a surgical splint (may be excluded by certificate)

Humana members may be eligible under the Plan for replacement of an occlusal orthotic appliance (replacement orthotics may be excluded by certificate) due to an anatomical change such as loss of teeth. For additional information regarding appliance replacement, please refer to Coverage Limitations section.

General Criteria for TMJ/TMD Surgery

Humana members may be eligible under the Plan for the surgical treatment of TMJ/TMD when ALL of the following criteria are met:

  • Individual is skeletally mature*; AND
  • Internal joint derangement or degenerative joint disease that has been confirmed by MRI or CT; AND
  • Symptoms persist despite documentation of compliance with at least 6 months of conservative treatments under the direction of a healthcare professional with one or more of the following:
    • Behavioral therapy; OR
    • Removable occlusal orthotic appliance therapy; OR
    • Medications (eg, analgesics, muscle relaxants or nonsteroidal anti-inflammatory drugs [NSAIDs]) when medically appropriate and not contraindicated; OR
    • Physical therapy (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
  • AND one of the following surgical procedures:
    • Arthrocentesis; OR
    • Arthroscopy; OR
    • Condylectomy; OR
    • Coronoidectomy; OR
    • Mandibular condylotomy; OR
    • Arthrotomy
      • Debridement; OR
      • Disc repair, repositioning or removal (with or without replacement); OR
    • Arthroplasty
      • Partial or total joint reconstruction by allogeneic graft or autogenous graft (alloplastic implants are not generally indicated for initial surgical treatment); OR
      • Partial or total joint replacement using an FDA-approved prosthesis may be indicated when ANY of the following criteria are met:
        • Failed alloplastic joint reconstruction; OR

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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
    Failed TMJ tissue graft reconstruction; OR
    Inflammatory or immunological responses (eg, end-stage deterioration, inflammatory arthritis) involving the TMJ; OR
    Loss of occlusal relationship and/or vertical mandibular height due to trauma, bone resorption, pathological lesion or developmental abnormality of the TMJ; OR
    Recurrent bony and/or fibrous ankylosis of the TMJ
    Documentation of further conservative treatment is not required for joint reconstruction utilizing a prosthetic device if there has been a previously failed alloplastic joint or TMJ tissue graft reconstruction. *Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases.

    Coverage Limitations
    EVALUATION

    Humana members may NOT be eligible under the Plan for the following diagnostic tests for TMJ/TMD:

    • Computerized mandibular scan; OR
    • Kinesiography; OR
    • Occlusal analysis; OR
    • Thermography; OR
    • Ultrasonography

    These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

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    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Note: The criteria for thermography are consistent with the Medicare National Coverage Policy, and therefore apply to Medicare members.

    TREATMENT

    Humana members may NOT be eligible under the Plan for the following treatments for TMJ/TMD:

    • Intra-aural devices (eg, TMJ NextGeneration); OR
    • Iontophoresis; OR
    • Jaw mobility mechanical stretching device (eg, Dynasplint System, OraStretch Press Jaw Motion Rehab System, TheraBite Jaw Motion Rehabilitation System)

    These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

    Humana members may NOT be eligible under the Plan for replacement of an occlusal orthotic appliance as this is generally excluded by certificate. In the absence of a certificate exclusion (unless replacement criteria in the Coverage Determination is met), this would be considered not medically necessary as defined in the member’s individual certificate.

    Humana members may NOT be eligible under the Plan for dental procedures for TMJ/TMD such as crowns, dental implants, dental restorations, extraction of wisdom teeth, fixed or removable partial dentures, full dentures, occlusal adjustment, onlays or orthodontics as these treatments are considered dental in nature and may be excluded by certificate.

    Additional information about temporomandibular joint disorders may be found from the following websites:

    Background
    • American Association of Oral and Maxillofacial Surgeons
    • National Institute of Dental and Craniofacial Research
    • National Library of Medicine

    Temporomandibular Joint Disorders Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0346-023 Page: 9 of 14

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Medical Alternatives

    Alternatives to temporomandibular joint disorders treatment include, but may not be limited to, the following:

    • Applying ice packs
    • Avoiding extreme jaw movements (eg, wide yawning, loud singing, gum chewing)
    • Eating soft foods
    • Prescription drug therapy
    • Relaxation techniques and jaw stretching exercises

    Physician consultation is advised to make an informed decision based on an individual's health needs.

    Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

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