by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
April 4th, 2017
Temporomandibular Joint (TMJ) Syndrome can include a wide variety of conditions that may be characterized as TMJ. Also there are a wide variety of methods for treating these conditions. Many of the procedures are excluded from coverage in the Medicare program for services or devices.
There are other services and appliances used to treat TMJ that fall within the Medicare program’s statutory exclusion at 1862(a)(12), which prohibits payment “for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth....”
For these reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom
must be determined to be considered medically necessary.