TMJ Medical Necesity and Documentation- Aetna

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 7th, 2015

Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction

For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit.  Reviews must include submission of a problem-specific history (i.e., Aetna Temporomandibular Disorder Questionnaire) and physical examination, TMJ radiographs/diagnostic imaging reports, patient records reflecting a complete history of 3 to 6 months of non-surgical management (describing the nature of the non-surgical treatment, the results, and the specific findings associated with that treatment), and the proposed treatment plan.  The provider will be notified of the coverage decision after review of all pertinent data.

Read the entire policy Aetna Policy Number 0028 last review 3/06/2015 Number 0028

CPT Codes / HCPCS Codes / ICD-9 Codes

 

CPT codes covered if selection criteria are met:

20552

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553

    single or multiple trigger point(s), 3 or more muscles

20605

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance [not covered for viscosupplementation injection]

20910

Cartilage graft; costochondral [autologous]

21010

Arthrotomy, tempomandibular joint

21050

Condylectomy, tempomandibular joint (separate procedure)

21060

Meniscectomy, partial or complete, tempomandibular joint (separate procedure)

21070

Coronoidectomy (separate procedure)

21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

21076

Impression and custom preparation; surgical obturator prosthesis

21079

    interim obturator prosthesis

21080

    definitive obturator prosthesis

21081

    mandibular resection prosthesis

21085

    oral surgical splint

21110

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21193

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

21198

Osteotomy, mandible, segmental;

21240

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242

Arthroplasty, temporomandibular joint, with allograft

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

21440

Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21445

Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21450

Closed treatment of mandibular fracture; without manipulation

21451

    with manipulation

21452

Percutaneous treatment of mandibular fracture; with external fixation

21453

Closed treatment of mandibular fracture with interdental fixation

21454

Open treatment of mandibular fracture with external fixation

21461

Open treatment of mandibular fracture; without interdental fixation

21462

    with interdental fixation

21465

Open treatment of mandibular condylar fracture

21470

Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints

21480

Closed treatment of temporomandibular dislocation; initial or subsequent

21485

    complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent

21490

Open treatment of temporomandibular dislocation

21497

Interdental wiring, for condition other than fracture

29800

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)

29804

Arthroscopy, temporomandibular joint, surgical

90832 - 90840

Psychotherapy

90901

Biofeedback training by any modality

97010

Application of a modality to 1 or more areas; hot or cold packs

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97124

    massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97530

Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97810

Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97811

    without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure)

97813

    with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97814

    with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure)

CPT codes not covered for indications listed in the CPB:

0232T

Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed

21120 - 21123

Genioplasty

21125 - 21127

Augmentation mandibular body or angle

21141 - 21147

Reconstruction midface, Lefort I

21150 - 21151

Reconstruction midface, Lefort II

21154 - 21155

Reconstruction midface, Lefort III (extracranial), any type, requiring bone grafts (includes obtaining autografts)

21159 - 21160

Reconstruction midface, Lefort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts)

21194

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

21195 - 21196

Reconstruction of mandibular rami and/or body, sagittal split

21199

Osteotomy, mandible, segmental; with genioglossus advancement

21206

Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21208 - 21209

Osteoplasty, facial bones

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

21248 - 21249

Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder)

70300

Radiologic examination, teeth; single view

70310

    partial examination, less than full mouth

70320

    complete, full mouth

70487

Computerized tomography, maxillofacial area; with contrast material(s)

70488

    without contrast material, followed by contrast material(s) and further sections

77077

Joint survey, single view, 2 or more joints (specify) [joint vibration analysis for TMJ]

95867

Needle electromyography; cranial nerve supplied muscle(s), unilateral

95868

    cranial nerve supplied muscles, bilateral

95887

Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure)

95937

Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method

97014

Application of a modality to 1 or more areas; electrical stimulation (unattended)

97024

    diathermy (e.g., microwave)

97026

    infrared

97028

    ultraviolet

97032

Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes

97033

    iontophoresis, each 15 minutes

97035

    ultrasound, each 15 minutes

97036

    Hubbard tank, each 15 minutes

97532

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

 

Other CPT codes related to the CPB:

70328

Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

70330

    bilateral

70332

Temporomandibular joint arthrography, radiological supervision and interpretation

70336

Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)

70486

Computerized tomography, maxillofacial area; without contrast material

70540

Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)

70542

    with contrast material(s)

70543

    without contrast material(s), followed by contrast material(s) and further sequences

HCPCS codes covered if selection criteria are met:

D0320

Temporomandibular joint arthrogram, including injection

D0321

Other temporomandibular joint films, by report

D0322

Tomographic survey

D0340

Cephalometric film

D5931 - D5933D5936

Obturator prostheses

D5934

Mandibular resection prosthesis with guide flange

D5982

Surgical stent

D5988

Surgical splint

D7630

Mandible, open reduction (teeth immobilized, if present)

D7640

Mandible, closed reduction (teeth immobilized, if present)

D7730

Mandible, open reduction

D7740

Mandible, closed reduction

D7810 - D7880

Reduction of dislocation and management of other temporomandibular joint dysfunctions

E0746

Electromyography (EMG), biofeedback device

S8262

Mandibular orthopedic repositioning device, each

 

HCPCS codes not covered for indications listed in the CPB:

A4556

Electrodes (e.g., apnea monitor), per pair

A4557

Lead wires (e.g., apnea monitor), per pair

A4558

Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz.

A4595

Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)

D0350

Oral/facial photographic images

D5110 - D5899

Prosthodontics (removable)

D6210 - D6999

Prosthodontics (fixed)

D7899

Unspecified TMD therapy, by report

D7940

Osteoplasty, for orthognathic deformities

D7941

Osteotomy - mandibular rami

D7943

Osteotomy - mandibular rami with bone graft; includes obtaining the graft

D7944

Osteotomy - segmented or subapical

D7945

Osteotomy, body of mandible

D7946

Lefort I (maxilla, total)

D7947

Lefort I (maxilla, segmented)

D7948

Lefort II or Lefort III (osteoplasty of facial bones for midfce hypoplasia or retrusion), without bone graft

D7949

Lefort II or Lefort III, with bone graft

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, autogenous or nonautogenous, by report

D7951

Sinus augmentation with bone or bone substitutes

D7953

Bone replacement graft for ridge preservation - per site

D7955

Repair of maxillofacial soft and/or hard tissue defect

D9940

Occlusal guards, by report

D9951

Occlusal adjustment, limited

D9952

Occlusal adjustment, complete

E0720

Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation

E0730

Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation

E0745

Neuromuscular stimulator, electronic shock unit

J7321

Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose [knee only - see selection criteria]

J7323

Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose [knee only - see selection criteria]

J7324

Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose [knee only - see selection criteria]

J7325

Hyaluronan or derivative, Synvisc, or Synvisc-One for intra-articular injection, per dose [knee only - see selection criteria]

 

ICD-9 codes covered if selection criteria are met:

524.60 - 524.69

Temporomandibular joint disorders

802.20 - 802.5

Fracture of mandible, closed or open, or malar and maxillary bones closed or open

830.0 - 830.1

Dislocation of jaw, closed or open

 

Other ICD-9 codes related to the CPB:

306.8

Other specified psychophysiological malfunction

327.00 - 327.8

Organic sleep disorders

346.00 - 346.93

Migraine

352.1

Glossopharyngeal neuralgia

715.1

Osteoarthrosis, localized, primary [temporomandibular joint]

715.28

Osteoarthrosis, localized, secondary [temporomandibular joint]

715.38

Osteoarthrosis, localized, not specified whether primary or secondary [temporomandibular joint]

718.18

Loose body in joint, other specified sites [temporomandibular joint]

718.28

Pathological dislocation, other specified sites [temporomandibular joint]

718.38

Recurrent dislocation of joint, other specified sites [temporomandibular joint]

719.18

Hemarthrosis, other specified sites [temporomandibular joint]

729.1

Myalgia and myositis, unspecified

733.40

Aseptic necrosis of bone, site unspecified

733.49

Aseptic necrosis of bone, other

780.50 - 780.59

Sleep disturbances

780.71

Chronic fatigue syndrome

784.0

Headache

908.6

Late effect of certain complications of trauma [scarring of temporomandibular joint that is severe and the result of old injury or prior procedure]

909.3

Late effect of complications of surgical and medical care [scarring of temporomandibular joint that is severe and the result of old injury or prior procedure]

959.09

Injury of face and neck [temporomandibular joint]

996.77 - 996.78

Other complications due to internal joint prosthesis and other internal orthopedic device, implant, and graft

V45.89

Other postprocedural states [head and neck tumor resection]

 

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

 

ICD-10 codes will become effective as of October 1, 2015 :

 

CPT codes covered if selection criteria are met:

20552

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553

    single or multiple trigger point(s), 3 or more muscles

20605

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance [not covered for viscosupplementation injection]

20910

Cartilage graft; costochondral [autologous]

21010

Arthrotomy, tempomandibular joint

21050

Condylectomy, tempomandibular joint (separate procedure)

21060

Meniscectomy, partial or complete, tempomandibular joint (separate procedure)

21070

Coronoidectomy (separate procedure)

21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

21076

Impression and custom preparation; surgical obturator prosthesis

21079

    interim obturator prosthesis

21080

    definitive obturator prosthesis

21081

    mandibular resection prosthesis

21085

    oral surgical splint

21110

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21193

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

21198

Osteotomy, mandible, segmental;

21240

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242

Arthroplasty, temporomandibular joint, with allograft

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

21440

Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21445

Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21450

Closed treatment of mandibular fracture; without manipulation

21451

    with manipulation

21452

Percutaneous treatment of mandibular fracture; with external fixation

21453

Closed treatment of mandibular fracture with interdental fixation

21454

Open treatment of mandibular fracture with external fixation

21461

Open treatment of mandibular fracture; without interdental fixation

21462

    with interdental fixation

21465

Open treatment of mandibular condylar fracture

21470

Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints

21480

Closed treatment of temporomandibular dislocation; initial or subsequent

21485

    complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent

21490

Open treatment of temporomandibular dislocation

21497

Interdental wiring, for condition other than fracture

29800

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)

29804

Arthroscopy, temporomandibular joint, surgical

90832 - 90840

Psychotherapy

90901

Biofeedback training by any modality

97010

Application of a modality to 1 or more areas; hot or cold packs

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97124

    massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97530

Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

97810

Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97811

    without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure)

97813

    with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97814

    with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure)

 

CPT codes not covered for indications listed in the CPB:

0232T

Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed

21120 - 21123

Genioplasty

21125 - 21127

Augmentation mandibular body or angle

21141 - 21147

Reconstruction midface, Lefort I

21150 - 21151

Reconstruction midface, Lefort II

21154 - 21155

Reconstruction midface, Lefort III (extracranial), any type, requiring bone grafts (includes obtaining autografts)

21159 - 21160

Reconstruction midface, Lefort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts)

21194

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

21195 - 21196

Reconstruction of mandibular rami and/or body, sagittal split

21199

Osteotomy, mandible, segmental; with genioglossus advancement

21206

Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21208 - 21209

Osteoplasty, facial bones

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

21248 - 21249

Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder)

70300

Radiologic examination, teeth; single view

70310

    partial examination, less than full mouth

70320

    complete, full mouth

70487

Computerized tomography, maxillofacial area; with contrast material(s)

70488

    without contrast material, followed by contrast material(s) and further sections

77077

Joint survey, single view, 2 or more joints (specify) [joint vibration analysis for TMJ]

95867

Needle electromyography; cranial nerve supplied muscle(s), unilateral

95868

    cranial nerve supplied muscles, bilateral

95887

Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure)

95937

Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method

97014

Application of a modality to 1 or more areas; electrical stimulation (unattended)

97024

    diathermy (e.g., microwave)

97026

    infrared

97028

    ultraviolet

97032

Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes

97033

    iontophoresis, each 15 minutes

97035

    ultrasound, each 15 minutes

97036

    Hubbard tank, each 15 minutes

97532

Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

 

Other CPT codes related to the CPB:

70328

Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

70330

    bilateral

70332

Temporomandibular joint arthrography, radiological supervision and interpretation

70336

Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s)

70486

Computerized tomography, maxillofacial area; without contrast material

70540

Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)

70542

    with contrast material(s)

70543

    without contrast material(s), followed by contrast material(s) and further sequences

 

HCPCS codes covered if selection criteria are met:

D0320

Temporomandibular joint arthrogram, including injection

D0321

Other temporomandibular joint films, by report

D0322

Tomographic survey

D0340

Cephalometric film

D5931 - D5933D5936

Obturator prostheses

D5934

Mandibular resection prosthesis with guide flange

D5982

Surgical stent

D5988

Surgical splint

D7630

Mandible, open reduction (teeth immobilized, if present)

D7640

Mandible, closed reduction (teeth immobilized, if present)

D7730

Mandible, open reduction

D7740

Mandible, closed reduction

D7810 - D7880

Reduction of dislocation and management of other temporomandibular joint dysfunctions

E0746

Electromyography (EMG), biofeedback device

S8262

Mandibular orthopedic repositioning device, each

References:

TMJ Medical Necesity and Documentation- Aetna. (2015, August 7). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/tmj-medical-necesity-and-documentation-aetna-31636.html

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