Humana Temporomandibular Disorders - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Applicable States/Territories Internet- Only Manuals (IOMs) NCD Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 §150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome Thermography Cosmetic and Reconstructive Surgery 220.11 L33428 Billing and Coding: Oral Maxillofacial Prosthesis LCD LCA Billing and Coding: Cosmetic and Reconstructive Surgery (effective 10/1/23) Facial Prostheses A53497 A56658 L33738 A52463 LCD LCA Ultrasound, Soft Tissues of the Head and Neck L34027 A57029 LCD LCA Temporomandibular Disorders Page: 2 of 11 Contractors (MACs) JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) DME A - Noridian Healthcare Solutions, LLC (DME MAC) DME B - CGS Administrators, LLC (DME MAC) DME C - CGS Administrators, LLC (DME MAC) DME D - Noridian Healthcare Solutions, LLC (DME MAC) JN - First Coast Service Options, Inc. (Part A/B MAC) AL, GA, TN NC, SC, VA, WV CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT IL, IN, KY, MI, MN, OH, WI AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, PR, U.S. VI AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, FL, PR, U.S. VI Temporomandibular Disorders Page: 3 of 11 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 Evaluation for TMJ/TMD often begins with physical examination, but may also involve muscle testing, radiographic imaging or range of motion measurements. 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 • 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 Temporomandibular Disorders Page: 4 of 11 • Iontophoresis – Uses an electrical current to deliver a medication through the skin or mucosa over the TMJ/TMD • 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 • Oral splints- Removable occlusal orthotic appliance therapy that maintains current bite or position of the jaw or teeth and is not utilized as an interim restorative support, such as oral surgical splint Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: EVALUATION Diagnostic testing for TMJ/TMD will be considered medically reasonable and necessary when 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); OR • Magnetic resonance imaging (MRI); OR • Radiographic imaging; OR • Ultrasonography 10, 26 General Criteria for TMJ/TMD Surgery Surgical treatment of TMJ/TMD will be considered medically reasonable and necessary when when ALL of the following criteria are met: • Internal joint derangement or degenerative joint disease that has been confirmed by MRI or CT; AND Temporomandibular Disorders Page: 5 of 11 • Symptoms persist despite documentation of compliance with at least 3 months of conservative treatments under the direction of a healthcare professional with one or more of the following: o Behavioral therapy; OR o Medications (eg, analgesics, muscle relaxants or nonsteroidal anti-inflammatory drugs [NSAIDs]) when medically appropriate and not contraindicated; OR o Physical therapy 10,26 AND one of the following surgical procedures 10: • Arthrocentesis; OR • Arthroscopy; OR • Condylectomy; OR • Coronoidectomy; OR • Mandibular condylotomy; OR • Arthrotomy o Debridement; OR o Disc repair, repositioning or removal (with or without replacement); OR • Arthroplasty o Partial or total joint reconstruction by allogeneic graft or autogenous graft (alloplastic implants are not generally indicated for initial surgical treatment)10; OR o Partial or total joint replacement using a FDA-approved prosthesis may be indicated when ANY of the following criteria are met 10: ▪ Failed alloplastic joint reconstruction; OR ▪ 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 28,29,30; OR Temporomandibular Disorders Page: 6 of 11 ▪ 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. The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage The following services/items will not be considered medically reasonable and necessary: • Computerized mandibular scan; OR • Dental procedures for TMJ/TMD such as crowns, dental implants, dental restorations, extraction of wisdom teeth, fixed or removable partial dentures, full dentures, occlusal analysis and adjustment, onlays or orthodontics; OR • • • 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); OR • Kinesiography; OR • Thermography These treatments and services fall within the Medicare program’s statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (§1862(a)(1) of the Act). Other services and appliances used to treat TMJ fall within the Medicare program’s statutory exclusion at 1862(a)(12), which prohibits payment.