This policy version was replaced October 3, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Temporomandibular Disorder (TMD) may be the result of congenital and developmental anomalies; fractures and dislocations resulting from trauma, internal derangement, or ankylosis (stiffening or fixation of a joint); or arthritic and neoplastic diseases. Symptoms attributed to TMD are varied and include, but are not limited to, clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; and tinnitus.

According to the National Institute of Dental and Craniofacial Research, experts strongly recommend initial use of the most conservative, reversible treatments possible. Such treatments do not invade the tissues of the face, jaw, or joint, or cause permanent changes in the structure or position of the jaw or teeth.

Definitions:

A qualified dentist is trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures; and is a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD).

NOTE:

• Use of biofeedback for treatment of temporomandibular disorder is addressed in policy II-70 Biofeedback
• See policy IV-07, Treatment of Obstructive Sleep Apnea and Snoring in Adults, for the use of morning repositioning devices.

Criteria for All Treatments

I.    Treatment of temporomandibular disorder (TMD) may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following diagnostic criteria are met, and criteria for specific treatments listed in sections II and III are met:

• Comprehensive examination, including history, physical, range of motion measurements of the jaw, and psychological evaluation as necessary; AND
• ALL of the following conditions have been ruled out by a medical doctor:
  • Acute and chronic rhinosinusitis;
  • Carotidynia;
  • Cervical spine pathology;
  • Disorders of the parotid gland;
  • Glossopharyngeal neuralgia;
  • Headache syndromes (e.g., migraine, cluster, tension);
  • Otologic disorders;
  • Trigeminal neuralgia;
• AND
• Panorex x-ray confirms internal derangement or arthritic changes of the temporomandibular joint;
• AND
• Persistent symptoms of TMD despite maximally tolerated drug therapy (e.g. NSAIDs), including two or more of the following:
  • Pain in the jaw, temple, ear, or in front of the ear;
  • Headache;
  • Radiating facial pain;
  • Limited movement or locking of the jaw;
  • Painful clicking, popping, or grating in the jaw when opening or closing the mouth;
  • Changes in the way the upper and lower teeth fit together;
• AND
• A full odontogenic exam has been completed and any pathology, including but not limited to dental caries, gingivitis, malocclusion, or bruxism, has been identified and treated by a qualified dentist; AND
• Diagnosed by a qualified dentist trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion, and associated oral structures.

Non-Surgical Treatments

II.   The following non-surgical treatments may be considered MEDICALLY NECESSARY AND APPROPRIATE in the treatment of temporomandibular disorder when the diagnostic criteria in section I have been met:: 

• Removable, intraoral appliances providing full-occlusal coverage;
• Physical therapy (includes modalities such as ultrasound, heat and cold treatments, iontophoresis, and manipulation);
• Transcutaneous electrical nerve stimulation (TENS);
• Behavioral/psychological therapy (i.e., relaxation training, cognitive behavioral therapies).

Surgical Treatments

III.  The following surgical treatments may be considered MEDICALLY NECESSARY AND APPROPRIATE in the treatment of temporomandibular disorder when the diagnostic criteria in section I have been met:

• Arthroscopic surgery in patients with objectively demonstrated (by physical examination and imaging) internal derangements or degenerative joint disease who have persistent TMJ pain and where conservative treatment for a minimum of 6 months has failed (e.g., orthotics/splints, analgesics, heat, muscle relaxants, physical therapy, jaw exercises, anti-inflammatory agents). 
• Manipulation for reduction of fracture or dislocation of the TMJ;
• Arthrocentesis;
• Open surgical procedures including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication and disc removal when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients where conservative treatment for a minimum of 6 months has failed.

Experimental / Investigative Treatments

IV.   The following non-surgical treatments are considered EXPERIMENTAL/INVESTIGATIVE in the treatment of temporomandibular disorder due to a lack of evidence demonstrating an impact on improved health outcomes:

• Electrogalvanic stimulation; 
• Prolotherapy; 
• Nociceptive Trigeminal Inhibition – tension suppression system (NTI-tss). 

V.  Arthroscopy of the temporomandibular joint solely for diagnostic purposes is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes.

Documentation Submission:

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

1. Clinical notes from a recent detailed oral examination documenting the absence of pathology (e.g., dental caries, gingivitis);
2. Clinical records documenting that other pathology (e.g., trigeminal neuralgia, otologic disorders) has been ruled out;
3. X-ray report signed by a radiologist.

Coverage

Note: For more information about the billing and reimbursement of dental services, please refer to Blue Cross Blue Shield of Minnesota Reimbursement policy Dental Services.

The following medical and surgical treatments are generally excluded from medical coverage under the member benefit document:

• Dental prostheses;
• Dental implants; 
• Dental restorations;
• Extraction of wisdom teeth.