Point32 Temporomandibular Joint Disorder Treatment Form

Harvard Pilgrim HealthCare Medical Policy

Temporomandibular Joint Disorder Treatment

Subject: Temporomandibular Joint Disorder Treatment

Authorization: Prior authorization is required for all treatments of temporomandibular joint disorders requested for members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Photographs— HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, Harvard Pilgrim Health Care (HPHC) draws upon the following InterQual® criteria:

• Arthroplasty, Temporomandibular Joint (TMJ) (2021)
• Arthroscopy, Temporomandibular Joint (TMJ) (2021)
• Reconstruction, Temporomandibular Joint (TMJ) (2021)

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers the treatment of temporomandibular joint disorders experimental/investigational for all other indications. In addition, HPHC does not cover:

• TMJ appliances, occlusal adjustment or other TMJ-related treatments, such as biofeedback, electromyography (e.g., surface electrode methods), hyaluronic acid injections
• Therapeutic manipulation of non-traumatic subluxation of TMJ requiring an anesthesia service (i.e., general or monitored anesthesia care)
• Jaw motion rehabilitation system (E1700-E1702), as it has been determined to be investigational.