Temporomandibular Disorders (019)

Number: 019
Update

Subject: Temporomandibular disorders

Reviewed: August 16, 2023

Important note

This Clinical Policy Bulletin determines whether certain services or supplies are medically necessary, experimental, and investigational, or cosmetic. Aetna® has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence -based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Bulletin.  The discussion, analysis, conclusions, and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute an opinion by Aetna and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided. 

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. 

The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Visit CMS's Coverage Database

Medical Clinical Policy Bulletin #0028  

March 17, 2023-This CPB has been revised to state that the following are considered experimental and investigational: (i) artificial intelligence technologies for the diagnosis of temporomandibular disorders (TMD); (ii) gallium aluminum arsenide laser therapy for the treatment of TMD with myofascial pain; and (iii) photo-biomodulation for the treatment of TMD and temporomandibular joint (TMJ) dysfunction.

See Medical Clinical Policy Bulletin 0028

Revision dates

Original policy: November 4, 2004
Updated: September 25, 2006; June 5, 2012; January 26, 2015; February 17, 2016; March 15, 2017; April 29, 2019; October 28, 2021; October 12, 2022; August 16, 2023
Revised: August 26, 2008; November 16, 2009; January 20, 2011; September 23, 2013; September 29, 2014; May 6, 2020

Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.