Diagnostic Procedures
The following diagnostic procedures may be considered medically necessary in the diagnosis of temporomandibular joint disorder (TMJD):
Diagnostic x-ray, tomograms, and arthrograms;
Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations);
Cephalograms (x-rays of jaws and skull);
Pantograms (x-rays of maxilla and mandible).
(Cephalograms and pantograms should be reviewed on an individual basis.)
The following diagnostic procedures are considered investigational in the diagnosis of TMJD:
Electromyography (EMG), including surface EMG;
Kinesiography;
Thermography;
Neuromuscular junction testing;
Somatosensory testing;
Transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaw that are associated with TMJD);
Muscle testing;
Standard dental radiographic procedures;
Range-of-motion measurements;
Computerized mandibular scan (measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJD);
Ultrasound imaging/sonogram;
Arthroscopy of the temporomandibular joint (TMJ) for purely diagnostic purposes;
Joint vibration analysis.
Nonsurgical Treatments
The following nonsurgical treatments may be considered medically necessary in the treatment of TMJD:
Intraoral removable prosthetic devices or appliances (encompassing fabrication, insertion, adjustment);
Pharmacologic treatment (eg, anti-inflammatory, muscle relaxing, analgesic medications).
The following nonsurgical treatments are considered investigational in the treatment of TMJD:
Electrogalvanic stimulation;
Iontophoresis;
Biofeedback;
Ultrasound;
Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function;
Orthodontic services;
Dental restorations/prostheses;
Transcutaneous electrical nerve stimulation;
Percutaneous electrical nerve stimulation;
Acupuncture;
Hyaluronic acid;
Platelet concentrates;
Dextrose prolotherapy.
Botulinum toxin A.
Surgical Treatments
The following surgical treatments may be considered medically necessary in the treatment of TMJD:
Arthrocentesis;
Manipulation for reduction of fracture or dislocation of the TMJ;
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;
Open surgical procedures (when TMJD results from congenital anomalies, trauma, or disease in individuals who have failed conservative treatment) including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication, and disc removal.
