When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
21010, 21240, 21242, 21243
DISLOCATION OF JAW
21480, 21485, 21490
21085, 21089, 21299
TEMPOROMANDIBULAR JOINT RECONSTRUCTION
20910, 21060, 21240, 21242, 21243, 21247
THE FOLLOWING CODE IS USED TO REPRESENT CONDYLOTOMY
M26.601 Right temporomandibular joint disorder, unspecified
M26.602 Left temporomandibular joint disorder, unspecified
M26.603 Bilateral temporomandibular joint disorder, unspecified
M26.609 Unspecified temporomandibular joint disorder, unspecified side
M26.611 Adhesions and ankylosis of right temporomandibular joint
M26.612 Adhesions and ankylosis of left temporomandibular joint
M26.613 Adhesions and ankylosis of bilateral temporomandibular joint
M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side
M26.621 Arthralgia of right temporomandibular joint
M26.622 Arthralgia of left temporomandibular joint
M26.623 Arthralgia of bilateral temporomandibular joint
M26.629 Arthralgia of temporomandibular joint, unspecified side
M26.631 Articular disc disorder of right temporomandibular joint
M26.632 Articular disc disorder of left temporomandibular joint
M26.633 Articular disc disorder of bilateral temporomandibular joint
M26.639 Articular disc disorder of temporomandibular joint, unspecified side
M26.69 Other specified disorders of temporomandibular joint
D7880 Occlusal orthotic device, by report
D9940 occlusal guard, by report; Removable dental appliances, which are designed to minimize the effects of bruxism (grinding) and other occlusal factors.
D9942 Repair and/or reline of occlusal guard
D9950 occlusion analysis - mounted case; Includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up; for diagnostic casts, see D0470.
D9951 occlusal adjustment - limited; May also be known as equilibration; reshaping the occlusal surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. Presently includes discing/odontoplasty/enamoplasty. Typically reported on a "per visit" basis. This should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics.
D9952 occlusal adjustment - complete; Occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain adequate relaxation of the musculature. Study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma.
L8699 Prosthetic implant, not otherwise specified
Policy: 07.00.01i:Biofeedback Therapy
Policy: 11.14.02o:Trigger Point Injections
Policy: 11.14.07u:Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
Policy: 11.14.24b:Manipulation Under Anesthesia
Policy: 12.01.01au:Experimental/Investigational Services