*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure or Service

The temporomandibular joints connect the lower jaw (mandible) to the temporal bones of the skull. Temporomandibular Joint Disease/Disorder (TMJ, TMD) refers to a spectrum of conditions, ranging from benign clicking with movement of the joint, to rheumatoid or degenerative arthritis, to internal derangement of the articular cartilage.

Symptoms vary but revolve around pain in the joint that may include myalgias, pain referred to the ear or other regions of the head or locking of the jaw due to muscle spasms.  In extreme cases, the member may not be able to open his/her mouth sufficiently to eat.  TMJ/TMD may be secondary to a variety of disorders including traumatic injury, habitual disuse of the joints, arthritis (rheumatoid or degenerative), etc.  Symptoms may come from myofascial pain, internal derangement of the joint, or from the arthritis process.  The symptom complex may progress to migraine and other craniofacial pain syndromes.

Therapies for correcting the dysfunction or the pain may include conservative measures or surgery. Conservative measures customarily include intra-oral appliances, physical therapy and pharmacologic pain control. Surgical procedures range from arthrocentesis (least invasive), arthroscopy (may include lavage, lysis of adhesions, instillation of medication, debridement and/or anterolateral capsular release), or arthrotomy (which may include arthroplasty; condylectomy; meniscus or disc plication and disc removal, and as a last resort, joint reconstruction using autogenous or alloplastic materials).

Policy Statement

Coverage will be provided for TMJ surgery when it is determined to be medically necessary, as outlined in the below guidelines and medical criteria.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination.  Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD);
• General coverage guidelines included in Original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan.  If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (EOC), the EOC always governs the determination of benefits.

Indications for Coverage

1. Documentation of a treatment plan by the participating physician, contracting oral surgeon or licensed dentist (when under the direction of a contracting MD) that will perform the TMJ/TMD surgery, should be submitted with the initial request;
   
                                              AND 
2. TMJ Surgery may be approved for members who meet all of the following criteria:
   1. Signs and symptoms not resolved by conservative measures (hard copy documentation of attempted conservative and failed treatment is required) including standard splints (unless contra- indicated, e.g., anterior open bite and some Class III malocclusions), pharmacological treatment and physical therapy (unless contra- indicated);
      
                                       AND 
      
   2. MRI or other radiology studies document TMJ abnormality noted in Stage III-V below;
      
                                        AND 
   3. Underlying orthodontic disorders have been ruled out, or if present, treatment has been implemented (history, physical, and/or laboratory results must be documented with an assessment of the presence or absence of an orthodontic disorder).
      
      
3. The following surgical procedures may be considered medically necessary in the treatment of TMJD:
   
   
   1. Arthrocentesis
      
   2. Arthroscopic surgery in individuals with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment.
   3. Open surgical procedures including, but not limited to, arthroplasties; condylectomies; meniscus or disc placation and disc removal when TMJD is the result of congenital anomalies, trauma, or disease in individuals who have failed conservative treatment.
   4. Arthrotomy with total prosthetic joint replacement using the TMJ Concepts Patient Fitted TMJ Reconstruction Prosthesis ™ is indicated for reconstruction of the TMJ for treatment of end-stage TMJ disease, when no other viable therapeutic alternatives are available.
      
      
      1. Individuals should be considered for total prosthetic joint replacement if they have one or more of the following conditions:
         
         
         1. Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment;
         2. Recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment;
         3. Failed tissue graft;
         4. Failed alloplastic joint reconstruction;
         5. Loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion.
             
      2. Total prosthetic joint replacement should not be used for individuals with one or more of the following conditions:
         
         
         1. Active or suspected infections in or about the implantation site;
         2. Uncontrollable masticatory muscle hyperfunction (clenching or grinding) which may lead to overload and loosening of screws;
         3. Known allergy to any of the component materials.
             
   5. Orthognathic Surgery – addressed in separate policy titled “Orthognathic Surgery.”
   6. Therapeutic manipulation of the TMJ requiring anesthesia (i.e., general or monitored anesthesia care) for reduction of fracture or dislocation of the TMJ.

When Coverage Will Not Be Approved

• Treatment when the member’s condition does not meet criteria above
• Therapy that is primarily dental in nature (occlusal/facet adjustment, etc.)
• As an adjunct to Orthodontic therapy (braces, banding, etc which are EOC exclusions) that is not medically necessary
• As an adjunct to Orthognathic surgery (EOC exclusion)
• Surgical treatment for Stage I and II TMJD symptoms (see table above) is considered not medically necessary.
• The following surgical treatments are considered investigational in the treatment of TMJ dysfunction:
  • Total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™
  • Partial joint replacement with the TMJ Fossa-Eminence Prosthesis™ 5. 

Billing/ Coding/physician Documentation Information

This policy may apply to the following codes.  Inclusion of a code in the section does not guarantee reimbursement. 

Applicable codes: 20605, 20606, 21010, 21050, 21060, 21070, 21073, 21116, 21240, 21242, 21243, 29800, 29804

Note: Codes 21089 and 21299 should not be reported for orthotic to treat temporomandibular joint dysfunction. This is not an appropriate code because an orthotic or splint for treatment of temporomandibular joint disease is not an “unlisted maxillofacial prosthetic procedure.”

The Plan may request medical records for determination of medical necessity.  When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Special Notes

• Covered services include clinical evaluation, diagnostic workup (including MRI and arthrograms), physical therapy, pharmacotherapy (if patient has pharmacy benefits), splints, and surgery (e.g., arthroscopy, arthroplasty, arthrocentesis/lavage).

Glossary of Terms

Adhesions: a fibrous band or structure in which parts adhere abnormally; may be referred to as scar tissue.
Alloplastic: pertaining to an inert foreign body used for implantation into tissue. For example, over time a variety of artificial materials have been used to reconstruct the TMJ, including plastics, teflon, silicone, various types of metals, and some combination materials. Arthrocentesis: the removal of fluid from a joint or bursa.
Arthroscopy: looking into the jaw joint with a special tube that has a light and a lens on the end.
Arthrotomy: surgical incision of a joint.
Autogenous: derived from the same organism, i.e., self-donation, also called autologous.
Condyle: the rounded articular surface at the articular end of a bone.
Crepitus: a crinkly, crackling or grating feeling or sound in the joints, skin or lungs.
Disc: the natural cushion in a joint.
Extra-articular: situated or occurring outside a joint.
Interincisal opening: the greatest distance between the front upper teeth and the front lower teeth when the mouth is open as wide as possible; normal is between 35-45 millimeters.
Internal derangement: problem within the joint itself, such as a disc out of place, rather than a problem in the tissues around the joint.
Lateral excursive movement: side to side motion, moving the jaw to the side. Malocclusion: abnormalities in the positioning and relationship of teeth. A deviation from normal occlusal relationship.
Mandible: lower jaw bones.
Myofascial: pertaining to or involving the fascia surrounding and associated with muscle tissue.
NSAIDs: non-steroidal anti-inflammatory drugs; medications that treat swelling, inflammation, and pain.
Occlusal splint: a device worn in the mouth that fits over the teeth to help take pressure off the jaw joint.
Occlusion: the contact relationship of the teeth in the maxilla and mandible in a closed position; often called "the bite."
Orthognathic surgery: surgery to reconstruct or change the position of the face and jaw bones and improve the way the teeth fit together.
Osseous: composed of, resembling, or capable of forming bone.
Osteophytes: a bony outgrowth.
Tinnitus: a noise in the ears, as ringing, buzzing, roaring, clicking, etc.

References:

1. BCBSNC Corporate Medical Policy “Temporomandibular Joint Dysfunction (TMJD) Treatment” Effective 10/2011; Accessed via  Temporomandibular Joint Dysfunction (TMJD) | Providers | Blue Cross NC (bluecrossnc.com) on 04/08/2025.
2. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services; Section 150.1: Dental    Services - Treatment of Treatment of Temporomandibular Joint (TMJ) Syndrome accessed via chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf on 04/08/2025
3. Milliman Care Guidelines; ACG-A- 0492 (AC) Temporomandibular Joint Arthroscopy accessed via MCG Health - 28th Edition on 04/08/2025
4. Milliman Care Guidelines; ACG-AC-0521 (AC) Temporomandibular Joint Modified Condylotomy accessed via MCG Health - 28th Edition on 04/08/2025
5. Milliman Care Guidelines; ACG–AC– 0522 (AC) Temporomandibular Joint Arthrotomy accessed via MCG Health - 28th Edition on 04/08/2025
6. Milliman Care Guidelines; ACG-AC-0523 (AC) Temporomandibular Joint Arthroplasty accessed via MCG Health - 28th Edition on 04/08/2025

Policy Implementation/Update Information:

Revision Dates:

November 1, 2001; December 13, 2001; December 31, 2001; June 22, 2005

May 16, 2007: No criteria changes made; Added staging chart for reference only; Added glossary of terms.

September 2009: Removed occlusal splints from policy- specific to TMJ surgery only; Removed 3-month limit to conservative treatment.

March 2012: No changes to the criteria.

February 9, 2015: Reviewed http://www.cms.gov & http://cgsmedicare.com; No NCD/LCD guidance for TMJ Surgery; Reviewed Dental Services LCD L31598; Revision Effective 3/13/14; Reviewed BCBS Corporate Medical Policy, Temporomandibular Joint Dysfunction; Reviewed Medicare Benefit Policy manual, Ch. 15 – 150.1.  No criteria changes noted.

February 15, 2017: No Criteria Changes noted. Minor Revisions only.

February 20, 2019: No Criteria Changes. Minor Revisions only.

February 17, 2021; Annual Review; No Criteria Updates. Minor Revisions Only.

February 15, 2023; Annual Review; No CMS Updates. Minor Revisions only

Approval Dates:

Medical Coverage Policy Committee: April 17, 2025         

Physician Advisory Group/UM Committee: 

Policy Owner: Amy Russo, LPN, Medical Policy Coordinator