Clinical Policy Title: Temporomandibular joint disorder Clinical Policy Number: 14.02.02 Effective Date: Initial Review Date: Most Recent Review Date: Next Review Date:

September 1, 2013 May 13, 2013 June 15, 2016 June 2017

Related policies: CP# 00.02.02 CP# 14.03.01

Botulinum toxin Orthognathic surgery

Policy contains:  TMJ — temporomandibular joint.  TMD — temporomandibular disorder.

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Specialized laboratories; Cerebral palsy; Spina bifida; Orthopedic surgery.

ABOUT THIS POLICY: AmeriHealth Caritas District of Columbia has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas District of Columbia’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies, along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas District of Columbia when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas District of Columbia’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas District of Columbia’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas District of Columbia will update its clinical policies as necessary. AmeriHealth Caritas District of Columbia’s clinical policies are not guarantees of payment.

Coverage policy AmeriHealth Caritas District of Columbia considers the treatment of temporomandibular joint (TMJ) disorder or temporomandibular disorder (TMD) to be mostly ineffective and, therefore, not medically necessary. Note: In District of Columbia, determinations of coverage are made on a case by case basis. Limitations: All other invasive or splinting therapies for temporomandibular joint disorder are not medically necessary. Alternative covered services: No evidence from the peer-reviewed literature supports the effectiveness of any treatments for TMJ disorder or TMD (see table, pages 2 – 4).

Background TMD, or TMJ disorder, is characterized by discomfort, sounds, or dysfunction (limited movement or locking of the jaw) in the temporomandibular joint and surrounding muscles or by occlusion of the teeth (grinding or bruxism). The disorder is multifactorial, including psychogenic contributors, with symptoms varying over time and apparently spontaneous remissions. It is also common, with 20 percent to 30 percent of adults experiencing symptoms. Attempts to treat this complex condition have included conservative and reversible modalities (reassurance, education, nonsteroidal anti-inflammatory drugs (NSAIDs), removable appliances such as night guards, behavioral and psychosocial interventions, biofeedback, and exposure to certain kinds of light) and irreversible modalities (arthrocentesis, occlusal adjustments orthodontics, joint replacement, injection of hyaluronate or Botulinum toxin into the joint, and orthognathic or corrective jaw surgery). (See policy #14.03.01 on orthognathic surgery.) Searches AmeriHealth Caritas District of Columbia searched PubMed and the databases of:  UK National Health Services Centre for Reviews and Dissemination.  Agency for Healthcare Research and Quality guideline clearinghouse and evidence-based practice centers.  The Centers for Medicare & Medicaid Services (CMS). We conducted searches on May 26, 2016. Search terms were: “temporomandibular joint” and “temporomandibular joint disorder.” We included:  Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.  Guidelines based on systematic reviews.  Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies. Overview of the literature: systematic reviews/guidelines and economic analyses for temporomandibular joint disorder: reverse chronological order and then alphabetically by first author. Findings Many reviewers found weak, inconclusive or otherwise insufficient evidence for firm conclusions about the effectiveness of diagnostic tests and/or interventions. No cost-effectiveness evidence is available. Policy updates: None.

Summary of clinical evidence: Citation CADTH (2013) Canadian Agency for Drugs and Technologies in Health

Content, Methods, Recommendations Key points:

Zongdao (Cochrane; 2013)

Key points:

Alberta Institute of Health Economics (2013)

Neuromuscular occlusion for diagnosis and treatment: insufficient evidence.

Hyaluronate: insufficient evidence. Key points:

De Souza (Cochrane; 2012)

Total prosthetic replacement: no available cost-effectiveness information. Key points:

Ebrahim (2012)

Interventions for temporomandibular osteoarthritis:  1950 ‒ 2011.  Randomized controlled trials (RCTs): comparing any forms of surgical or nonsurgical therapies in adults with clinical and radiographic confirmation of osteoarthritis.  Three trials only: meta-analysis precluded.  Insufficient evidence. Key points:

Katsnelson (2012)

Splint therapy:  Eleven eligible studies.  Promising, but more research is needed. Key points:

Aggarwal (Cochrane; 2011)

 TMJ ankylosis: Four studies only. Insufficient evidence. Key points:

Rigon (Cochrane; 2011)

Psychosocial interventions for chronic orofacial pain:  1950 ‒ 2010.  RCTs: nonpharmacological psychosocial interventions vs. any other form or treatment.  Conclusions: evidence is weak, but noninvasive nature may encourage use. Key points:

Arthroscopy for TMD

AAPD(2010) Acquired TMD in infants, children, adolescents

1980 ‒ 2011: RCTs. Both arthroscopy and open surgery reduced pain after six months. Open surgery was more effective after 12 months. Arthroscopy more effective than arthrocentesis at increasing opening after 12 months, but no difference in pain. Key points:    

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1985 ‒ 2010. Consensus recommendations. Assessment should include: history and physical for pain, dysfunction, previous trauma. Reversible therapies: patient education, physical therapy, behavioral, prescription drugs, occlusal splints. Avoidance of irreversible: occlusal adjustment, mandibular repositioning, orthodontics due to lack of evidence in this population.

Citation Luther (Cochrane; 2010)

Content, Methods, Recommendations Key points:

Orthodontics for TMJ disorders Mujakperuo (Cochrane; 2010)

 2010: RCTs in adults.  Insufficient evidence. Key points:

Pharmacological interventions for pain in TMD CADTH (2009) Canadian Agency for Drugs and Technologies in Health Guo (Cochrane; 2009)

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1950 ‒ 2010. RCTs: agent vs. placebo; but not parenteral administration. Insufficient evidence.

Key points: Botulinum toxin: insufficient evidence. Key points:

Arthrocentesis and lavage for TMJ Al-Riyami (2009)

 1980 ‒ 2009: Chinese-language RCTs and quasi-experimental.  Insufficient evidence. Key points:

Orthognathic treatment and TMD

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Shi (Cochrane; 2009) Hyaluronate (intra-articular injection) for TMJ Hayes (2008) Low-level light therapy for TMJ pain

Hayes (2006) TMJ reconstruction with patient-fitted TMJ prosthesis (TMJ concepts)

Search dates not reported: RCTs, case-control, cohort synthesized narratively. Fifty-three studies (N = 8028). Meta-analysis included a small number of studies, substantial heterogeneity, and no definitive results. Key points:  RCTs, 1980 ‒ 2001.  Seven studies, 109 subjects.  Insufficient evidence. Key points:  1996 ‒ 2008.  Placebo-controlled trials, English.  Six small trials of variable quality.  Mixed and inconclusive results. Key points:     

2001 ‒ 2006: relevant English language studies. Controlled and uncontrolled studies suggest that prosthesis provides statistically and clinically significant long-term improvements in pain, jaw opening, function, and dietary restrictions. Patients with severe TMJ disorder who have failed grafting may benefit. Complications: heterotropic bone formation (20%); infection/immunologic reaction (3%); loosening, dislocation, or incorrect fit (6%); follow –up (FU) ≥ 2 years, 8% required or requested removal. Contraindications: infection at implantation site, bruxism or other masticatory muscle hyperfunction, allergy to prosthesis materials.

Ziad (Cochrane; 2004)

Key points:

Stabilization splint therapy

 1966 ‒ 2001.  RCTs: stabilization vs. no therapy, other occlusal appliance, or other active intervention.  Twelve studies pooled.  Insufficient evidence. Key points:

Koh (Cochrane; 2003)

Citation Occlusal adjustment for treating and preventing temporomandibular joint disorders in adults Kim (2002)

Content, Methods, Recommendations  1966 ‒ 2002.  RCTs: adjustment vs. placebo, reassurance or no adjustment.  Six trials (392 subjects) pooled: no difference between intervention and control.

Orthodontic treatment for TMD

 1966 ‒ 2000.  RCTs; cohort; case-control; “prospective.”  Inconclusive. Key points:

Crider (1999) EMG biofeedback for TMD

Forssell (1999) Occlusal treatments in TMD

Key points:

 1966 ‒ 1997.  Controlled clinical trial(CCTs0 vs. placebo or no treatment.  Pre- to post-procedure differences approached significance at P < 0.10.  Inclusive due to limitations in this review’s reporting controlled reults data (CRD). Key points:     

Occlusal splint or adjustment. Excluded: comparisons of different types of splints or combination occlusal with other treatment. RCTs, 1966 ‒ 1999. No language restrictions. Included study limitations = results suggestive not conclusive: splints may have some benefit, but there is no evidence for adjustment.

Glossary Arthrocentesis — Using a needle to puncture, irrigate, or remove fluid from the joint; sometimes accompanied by manipulation and usually with local anesthesia. Botulinum toxin — A bacterial toxin used to treat muscle spasm or other involuntary movement (see policy # 00.02.02 botulinum toxin). Medically necessary — A service or benefit is medically necessary if it is compensable under the Medical Assistance program and if it meets any one of the following standards:  The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.  The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.  The service or benefit will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for members of the same age. Nonsteroidal anti-inflammatory drugs (NSAIDs) — A class of drugs with both analgesic and antiinflammatory effects. They include ibuprofen (Advil®) and naproxen (Aleve®) and are available over the counter in the United States. They are used for acute and chronic conditions involving pain and inflammation, such as osteoarthritis, rheumatoid arthritis, low back pain, headache, and toothache. Since gastrointestinal side effects are prominent, they should be avoided by people with dyspepsia or other existing gastrointestinal conditions, such as diarrhea or bleeding.

Hyaluronate or hyaluronic acid — A major component of cartilage, the tissue lining most internal joint surfaces. Low-level light therapy — A procedure wherein a low-intensity (infrared or visible red) laser beam is directed onto skin overlying inflamed tissues with the intent of reducing pain and promoting healing. Occlusal adjustment — Grinding the contacting areas of teeth to improve function. Orthognathic surgery — Orthognathic surgical procedures are used to correct improper alignment of upper and lower jaws when such misalignment cannot be corrected by movement of teeth (orthodontics) within existing configurations of bone alone. Jaw misalignment problems can be evidenced as functional (chewing, speech, or swallowing problems; difficulty breathing during sleep [sleep apnea]) or esthetic (open bite; protruding or receding chin). References Professional society guidelines/other: Canadian Agency for drugs and Technologies in Health. Neuromuscular occlusion for diagnosis and treatment of temporomandibular joint disorders: a review of the clinical evidence. Rapid Response report. 2013. Canadian Agency for drugs and Technologies in Health. Botulinum toxin A for the treatment of trigeminal neuralgia and temporomandibular joint dysfunction: a review of the clinical effectiveness. Health Technology Inquiry Service. 2009. Institute of Health Economics. Total prosthetic replacement of the temporomandibular joint: A rapid evidence assessment and economic analysis. Edmonton AB: Institute of Health Economics. 2013. American Association of Oral and Maxillofacial Surgeons. Statement concerning the management of selected clinical conditions and associated clinical procedures. Temporomandibular Disorders. http://www.aaoms.org/images/uploads/pdfs/tmj_disorders.pdf. Accessed May 26, 2016. Peer-reviewed references Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev. 2011. Issue 11. Craane B, de Laat A, Dijkstra PU, Stappaerts K, Steganga B. Physical therapy for the management of patients with temporomandibular disorders and related pain. Cochrane Database Syst Rev.2006. Issue 1. Crider AB, Glaros AG. A meta-analysis of EMG biofeedback treatment of temporomandibular disorders. J Orofac Pain. 1999; 13(1):29 – 37. Forsell H, Kalso E, Koskela P, Vehmanen R, Puukka P, Alanen P. Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomized controlled trials. Pain.1999; 83(3):549 – 60. Guo C, Shi Z, Revington P. Arthrocentesis and lavage for treating temporomandibular joint disorders. Cochrane Database Syst Rev. 2009, issue 4.

Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibular disorder: a meta-analysis. Am J Orthod Dentofacial Orthop. 2002; 121(5): 438 – 46. Hayes, Inc. Low level light therapy for temporomandibular joint pain. May 12, 2008. Koh H, Robinson P. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev. 2003. issue 1. Luther F, Layton S, McDonald F. Orthodontics for temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev.2010, Issue 7. Mujakperuo HR, Watson M, Morrison R, McFarlane TV. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev. 2010. Issue 10. Rigon M, Pereira LM, Bortoluzzi MC, Loguercio AD, Ramos AL. Cardoso JR. Arthroscopy for temporomandibular disorders. Cochrane Database Syst Rev. 2011. Issue 5. Shi X, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders. Cochrane Database Syst Rev. 2009. Issue 1. Ebrahim S, Busse JW, Guyatt GH. The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc. 2012; 143(8): 847 – 57. Kastsnelson A, Markiewicz MR, Keith DA, Dodson TB. Operative management of tempormandibular joint ankylosis: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2012; 70(3):531 – 6 Wright EF, North SL. Management and treatment of temporomandibular disorders: a clinical perspective. J Man Manip Ther. 2009; 17(4): 247 – 254. PMCID: PMC2813497. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813497/. Accessed May 13, 2015. Zongdao, S, Chunlan G, Awad, M. Hyaluronate for temporomandibular joint disorders. Cochrane Database Syst Rev. 2013. Issue 10. Clinical trials: Reviews in the evidence table (pages 3 – 5) cover trials published through 2012. CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Codes

Description

20650

Arthrocentesis, aspiration and/or injection of temporomandibular joint or bursa

21050

Condylectomy, temporomandibular joint

21060

Meniscectomy, partial or complete, temporomandibular joint

21070

Coronoidectomy

21073

Manipulation of temporomandibular joint(s), requiring anesthesia

21240

Arthroplasty, temporomandibular joint, with or without autograft

21242

Arthroplasty, temporomandibular joint, with allograft

21243

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

21247

Cartilage graft, mandibular condyle

29800

Arthroscopy, temporomandibular joint, diagnostic, with or without biopsy

29804

Arthroscopy, temporomandibular joint, surgical

ICD-10 Code

Description

M26.60

Temporomandibular joint disorder, unspecified

M26.61

Adhesions and ankylosis of temporomandibular joint

M26.62

Arthralgia of temporomandibular joint

M26.63

Articular disc disorder of temporomandibular joint

M26.69

Other specified disorders of temporomandibular joint

HCPCS Code N/A

Description

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