Clinical UM Guideline
Subject: Temporomandibular Disorders
Guideline #: CG-SURG-09 Publish Date: 01/03/2024
Status: Revised Last Review Date: 11/09/2023

This document addresses treatments for conditions of the temporomandibular joint (TMJ) and related musculoskeletal structures. Such conditions are commonly referred to as temporomandibular disorders (TMD), temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndrome, or craniomandibular disorder (CMD).

Note: Please refer to the following documents for additional information on related topics:


Clinical Indications

Medically Necessary:

Intraoral appliances (for example, occlusal splints, bite appliances, and mandibular occlusal repositioning appliances) are considered medically necessary for temporomandibular disorders.

Surgical procedures are considered medically necessary for the treatment of temporomandibular disorders when the following criteria are met (A and B):

  1. Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by the following:
    1. Radiographic documentation of temporomandibular joint pathology (for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors); and
    2. For individuals age under the age of 18: documentation of completion of skeletal growth by either:
      1. Long bone x-ray; or
      2. Serial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;
  2. Either of the following:
    1. Temporomandibular joint pain is due to a maxillary or mandibular skeletal deformity; or
    2. The individual has a clinically significant functional impairment refractory to at least 6 months of non-surgical treatment.

Not Medically Necessary:

The following nonsurgical treatments are considered not medically necessary for temporomandibular disorders include, but are not limited to, the following:

  1. Electrogalvanic stimulation (EGS); or
  2. Jaw motion rehabilitation systems; or
  3. Mandibular image-guided rehabilitative orthopedics (also known as MIRO Therapy®); or
  4. Occlusal equilibration, bite adjustment, irreversible occlusion therapy.

Surgical procedures for temporomandibular disorders are considered not medically necessary when the above criteria are not met.

The following diagnostic tests and procedures are considered not medically necessary when used to diagnose or evaluate temporomandibular disorders:

  1. Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording muscle activity related to mandibular movement or positioning); or
  2. Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning); or
  3. Electromyography (including percutaneous or surface electrode methods); or
  4. Kinesiography; or
  5. Laryngeal function studies; or
  6. Rhinomanometry; or
  7. Somatosensory testing/neuromuscular junction testing; or
  8. Swallowing studies or tests; or
  9. Thermography.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:




Occlusal orthotic device, by report [when specified as removable TMJ splints, mandibular occlusal repositioning appliances]



ICD-10 Diagnosis



Temporomandibular joint disorders

When services may be Medically Necessary when criteria are met:




Including, but not limited to, the following:


Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance [when specified as temporomandibular joint aspiration]


Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting [when specified as temporomandibular joint aspiration]


Arthrotomy, temporomandibular joint


Condylectomy, temporomandibular joint (separate procedure)


Meniscectomy, partial or complete, temporomandibular joint (separate procedure)


Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)


Application of interdental fixation device for conditions other than fracture or dislocation, includes removal


Injection procedure for temporomandibular joint arthrography


Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)


Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)


Arthroplasty, temporomandibular joint, with allograft


Arthroplasty, temporomandibular joint, with prosthetic joint replacement


Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)


Arthroscopy, temporomandibular joint, surgical






Open reduction of dislocation


Closed reduction of dislocation


Manipulation under anesthesia




Surgical discectomy, with/without implant


Disc repair






Joint reconstruction








Nonarthroscopic lysis and lavage


Arthroscopy- surgical: lavage and lysis of adhesions


Arthroscopy- surgical: disc repositioning and stabilization


Arthroscopy- surgical: synovectomy


Arthroscopy- surgical: discectomy


Arthroscopy- surgical: debridement


Unspecified TMD therapy, by report



ICD-10 Procedure



Excision of right temporomandibular joint, open approach


Excision of right temporomandibular joint, percutaneous approach


Excision of right temporomandibular joint, percutaneous endoscopic approach


Excision of left temporomandibular joint, open approach


Excision of left temporomandibular joint, percutaneous approach


Excision of left temporomandibular joint, percutaneous endoscopic approach


Repair right temporomandibular joint [includes codes 0RQC0ZZ, 0RQC3ZZ, 0RQC4ZZ]


Repair left temporomandibular joint [includes codes 0RQD0ZZ, 0RQD3ZZ, 0RQD4ZZ]


Reposition right temporomandibular joint [includes codes 0RSC04Z, 0RSC0ZZ, 0RSC34Z, 0RSC3ZZ, 0RSC44Z, 0RSC4ZZ, 0RSCX4Z, 0RSCXZZ]


Reposition left temporomandibular joint [includes codes 0RSD04Z, 0RSD0ZZ, 0RSD34Z, 0RSD3ZZ, 0RSD44Z, 0RSD4ZZ, 0RSDX4Z, 0RSDXZZ]


Supplement right temporomandibular joint [includes codes [0RUC07Z, 0RUC0JZ, 0RUC0KZ, 0RUC37Z, 0RUC3JZ, 0RUC3KZ, 0RUC47Z, 0RUC4JZ, 0RUC4KZ]


Supplement left temporomandibular joint [includes codes 0RUD07Z, 0RUD0JZ, 0RUD0KZ, 0RUD37Z, 0RUD3JZ, 0RUD3KZ, 0RUD47Z, 0RUD4JZ, 0RUD4KZ]



ICD-10 Diagnosis



Other headache syndrome


Primary osteoarthritis, other specified site


Primary osteoarthritis, unspecified site


Dentofacial functional abnormalities


Temporomandibular joint disorders


Myalgia, unspecified; mastication muscle; auxiliary muscles, head and neck


Dislocation of jaw

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

When services are also Not Medically Necessary:
For the diagnosis codes listed above for TMD and related diagnoses, for the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.




Occlusion analysis- mounted case


Occlusal adjustment- limited


Occlusal adjustment- complete


Jaw motion rehabilitation system


Replacement cushions for jaw motion rehabilitation system, package of 6


Replacement measuring scales for jaw motion rehabilitation system, package of 200

Discussion/General Information

Temporomandibular disorders (TMD) is a collective term for temporomandibular joint dysfunction (TMJD), temporomandibular joint (TMJ) syndromes, and craniomandibular disorder (CMD), that includes a variety of medical and dental conditions involving the masticatory muscles and the temporomandibular joint, as well as contiguous tissue components. The prevalence of TMJD is in the range of 5 to 12% (NIDCR, 2018). The incidence is higher in younger individuals and in women. Although some cases can be linked to physical trauma or disease conditions, in most cases the cause is unknown.

The most frequent presenting symptom associated with TMD is pain, usually localized to the muscles of mastication, the preauricular area, and/or the TMJ. This pain may be related to trauma, (such as a blow to the face), inflammatory or degenerative arthritis, or may be due to the mandible being pushed back towards the ears whenever the individual chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening the mouth normally. Other common complaints reported by individuals include earache, headache, and facial pain. Individuals may also have limited or asymmetric jaw movement and joint sounds that are usually described as clicking, popping, grating, or crepitus in the TMJ.

Most cases of TMD can be treated without surgery. Treatments may include behavioral changes, physical therapy, pharmacologic therapy (e.g., oral medications for pain, anti-inflammatory injections), and reversible, removable, intraoral dental splints (also called occlusal orthotics or occlusal splints). Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases. Such procedures include but are not limited to the following:

There are no criteria to identify people who would most likely benefit from surgery. A review of available published evidence regarding the safety and efficacy of various medical and surgical treatment modalities for TMJ revealed inconsistent methodologies in study design and  clinical outcome measurements (Al-Moraissi, 2017; Bouchard, 2017; Nandhini, 2018; Schiffman, 2007; Tatli, 2017; Truelove, 2006; Zhang, 2020).

In 2014, Schiffman and colleagues found that, although the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been reliable, they were below the target sensitivity of greater than or equal to 0.70 and specificity of greater than or equal to 0.95. This empirical finding prompted a revision. The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I include both a valid screening protocol for detecting any pain-related TMD, as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity greater than or equal to 0.86, specificity greater than or equal to 0.98). The authors stated:

TMD is the second most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability… Taken together, a new dual-axis Diagnostic Criteria for TMD (DC/TMD) will provide evidence-based criteria for the clinician to use when assessing patients, and will facilitate communication regarding consultations, referrals, and prognosis.

In 2017, the American Academy of Oral and Maxillofacial Surgeons (AAOMS) issued Parameters of Care (6th edition) which stated the following:

Temporomandibular joint (TMJ) surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection…Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient.

The National Institute of Dental and Craniofacial Research (2023) states the following on temporomandibular joint and muscle disorders:

Open surgery gives access to the temporomandibular joint through a cut (incision) next to the ear. It’s important to know that surgery makes permanent changes to your joint. There are no long-term research studies on the safety of open surgery for TMDs or on how well it works to relieve symptoms.

Surgery should only be considered if:

Several devices have obtained pre-market approval or clearance from the U.S. Food and Drug Administration (FDA) for the surgical treatment of TMD. The FDA-approved labeling for these devices has similar indications. However, the published evidence evaluating clinical outcomes of these devices is limited and clinical utility has not been empirically established.


Analgesics: Medications that provide pain relief.

Arthroplasty: Surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.

Craniomandibular disorder (CMD): A dental term used to describe diseases or disorders of the muscles of the head and neck, with special reference to the masticatory (chewing) muscles.

Disc: Shortened terminology for an intervertebral disc or a TMJ disc; a disk-shaped piece of specialized tissue that separates the bones and provides a cushion between the bones.

Mandible: Bone of the lower jaw.

Meniscus: A cartilage pad between the two joint surfaces within the TMJ, acting as a smooth surface for the joint to move on.

Modified condylotomy: An extra-articular surgical procedure used to manage TMJ dysfunction. The primary purpose of the procedure is to increase joint space by allowing the mandibular condyle to move inferiorly with respect to both the articular disc and eminence.

Occlusal orthotic device: A dental term used to describe a reversible, removable intraoral appliance, such as a splint.

Orthodontics: The specialty of dentistry dealing with the prevention and correction of abnormally positioned or aligned teeth.

Temporal bone: A large, irregular bone situated at the base and side of the skull; connected with the mandible via the TMJ.

Temporomandibular joint (TMJ): Joint that hinges the mandible to the temporal bone of the skull; one of the most frequently used joints in the entire body, moving whenever a person eats, drinks, or talks.


Peer Reviewed Publications:

  1. Al-Moraissi EA, Wolford LM, Perez D, et al. Does orthognathic surgery cause or cure temporomandibular disorders? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(9):1835-1847.
  2. Bouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular lavage versus nonsurgical treatments for temporomandibular disorders: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75(7):1352-1362.
  3. Bouloux GF. Modified condylotomy for temporomandibular joint dysfunction. Atlas Oral Maxillofac Surg Clin North Am. 2011; 19(2):169-175.
  4. Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: A systematic review and meta-analysis. J Am Dent Assoc. 2012; 143(8):847-857.
  5. Hall HD, Indresano AT, Kirk WS, Dietrich MS. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005; 63(8):1174-1179.
  6. Hall HD, Navarro EZ, Gibbs JS. One- and three year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg. 2000; 58(1):7-17.
  7. Keller EE, Baltali E, Liang X, et al. Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study. J Oral Maxillofac Surg. 2012; 70(2):276-288.
  8. Lindenmeyer A, Sutcliffe P, Eghtessad M, et al. Oral and maxillofacial surgery and chronic painful temporomandibular disorders--a systematic review. J Oral Maxillofac Surg. 2010; 68(11):2755-2764.
  9. Linsen SS, Reich RH, Teschke M. Mandibular kinematics in patients with alloplastic total temporomandibular joint replacement-a prospective study. J Oral Maxillofac Surg. 2012; 70(9):2057-2064.
  10. Manfredini D, Rancitelli D, Ferronato G, Guarda-Nardini L. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil. 2012; 39(4):245-251.
  11. Marques FBC, de Lima LS, Oliveira PLE, Magno MB et al. Are temporomandibular disorders associated with facial asymmetry? A systemic review and meta-analysis. Orthod Craniofac Res. 2021; 24(1): 1-16.
  12. McLeod NM, Saeed NR, Hensher R. Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis. Br J Oral Maxillofac Surg. 2001; 39(1):63-66.
  13. Nandhini J, Ramasamy S, Ramya K, et al. Is nonsurgical management effective in temporomandibular joint disorders? A systematic review and meta-analysis. Dent Res J (Isfahan). 2018; 15(4):231-241.
  14. Schiffman EL, Look JO, Hodges JS, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007; 86(1):58-63.
  15. Tatli U, Benlidayi ME, Ekren O, Salimov F. Comparison of the effectiveness of three different treatment methods for temporomandibular joint disc displacement without reduction. Int J Oral Maxillofac Surg. 2017; 46(5):603-609.
  16. Truelove E, Huggins KH, Manci L, Dworkin SF. The efficacy of traditional, low cost, and non-splint therapies for temporomandibular disorder. J Am Den Assoc. 2006; 137(8):1099-1107.
  17. Valesan LF, Da-Cas CD, Reus JC, et al. Prevalence of temporomandibular joint disorders: a systematic review and meta-analysis.Clin Oral Investig. 2021; 25(2):441-453.
  18. Werther JR, Hall HD, Gibbs JS. Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):668-679.
  19. Widmalm S, Brooks S, Sano T, et al. Limitation of the diagnostic value of MR images for diagnosing temporomandibular joint disorders. Dentomaxillofac Radiol. 2006; 35(5):334-338.
  20. Wolford LM. Factors to consider in joint prosthesis systems. Proc (Bayl Univ Med Cent). 2006; 19(3):232-238.
  21. Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of two temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg. 2003a; 61(6):685-690.
  22. Wolford LM, Pitta MC, Reiche-Fishel O. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003b; 32(3):268-274.
  23. Yuasa H, Kurita K. Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol & Endod. 2001; 91(6):671-675.
  24. Zhang SH, He KX, Lin CJ, et al. Efficacy of occlusal splints in the treatment of temporomandibular disorders: a systematic review of randomized controlled trials. Acta Odontol Scand. 2020; 78(8):580-589.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Oral and Maxillofacial Surgery (AAOMS). Parameters of care: clinical practice guidelines for oral and maxillofacial surgery. 2017. Available at: Accessed on September 11, 2023.
  2. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical condition statements: temporomandibular disorders. 2017. Available at: Accessed on September 11, 2023.
  3. American Association for Dental Research (AADR). Policy statement: temporomandibular joint disorders (TMJ). Adopted 1996; reaffirmed 2015. Available online at: Accessed on September 11, 2023.
  4. de Souza RF, Lovato da Silva CH, Nasser M, et al. Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012;(4):CD007261.
  5. National Institutes National Institute of Dental and Craniofacial Research (NIDCR). 2018a. Prevalence of TMJD and its Signs and Symptoms. Last reviewed July 2018. Available at: Accessed on September 11, 2023.
  6. National Institutes National Institute of Dental and Craniofacial Research (NIDCR). 2023. TMJ (Temporomandibular Joint & Muscle Disorders). Last updated March 2023. Available at: Accessed on September 11, 2023.
  7. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network (International Association for Dental Research) and Orofacial Pain Special Interest Group (International Association for the Study of Pain). J Orol Fac Pain Headache. 2014; 28(1):6-27.

Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
MIRO Therapy
Patient-Fitted TMJ Reconstruction Prosthesis
Temporomandibular Joint
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis
TMJ Fossa-Eminence Prosthesis System
TMJ Fossa-Eminence Prosthesis System
TMJ Patient Specific Fossa-Eminence Prosthesis System
Total Temporomandibular Joint (TMJ) Replacement System (Biomet Microfixation).
TMJ Partial Temporomandibular Joint Replacement System,
Total Temporomandibular Joint (TMJ) Replacement System

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.







Medical Policy & Technology Assessment Committee (MPTAC) review.  Revised formatting of MN statement. Revised surgical procedures criteria. Added MIRO Therapy to NMN statement. Updated Discussion, References, and Index sections.



MPTAC review. Moved content related to iontophoresis to CG-MED-28. Removed content from MN and NMN statements that are addressed in other documents. Updated formatting in Clinical Indications section. Updated Description, Discussion, References and Index sections. Updated Coding section, removed 97033, D9130, D9920 no longer addressed.



MPTAC review. Updated References sections.



MPTAC review. Added “or’s” to list of surgical procedures in medically necessary statement. Edited criterion B in medically necessary statement on surgical procedures for clarification.  Modified ‘not medically necessary’ statement on surgical procedures to include “when the above criteria are not met”. Discussion/General Information and References sections updated. Reformatted Coding section.



Updated Coding section with 10/01/2020 ICD-10-CM changes; added M19.09.



MPTAC review. Pharmacologic therapy and therapeutic injections removed from medically necessary statement on nonsurgical treatments. Intra-articular injections of hyaluronic acid removed from not medically necessary statement. Discussion/General Information and References sections updated.



Updated Coding section to correct ICD-10-CM diagnosis codes S03.00XA-S03.03XS.



MPTAC review. Clarified MN and NMN criteria and removed requirement for FDA approval. Description, Discussion/General Information, and References sections updated. Updated Coding section; removed D9940 deleted 12/31/2018; added 97033, D9130, D9920.



Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added M79.10-M79.12 replacing M79.1.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Discussion/General Information and References sections updated.



MPTAC review. Modified condylotomy was added to the surgical procedures for TMD considered medically necessary when criteria are met. References and Coding sections were updated.



MPTAC review. Updated the formatting of the Clinical Indications section. The Discussion section and References were updated.



Updated coding section with 10/01/2016 ICD-10-CM changes.



MPTAC review. References were updated. Removed ICD-9 codes from Coding section.



Updated Coding section with 07/01/2015 HCPCS changes; removed S8262 deleted 06/30/2015.



MPTAC review. Discussion and References sections were updated. Updated Coding section with 01/01/2015 CPT changes.



MPTAC review. Discussion section and References were updated.



MPTAC review. References were updated.



MPTAC review. Discussion and References were updated.



MPTAC review. Revised Subject of document to: Temporomandibular Disorders. Clarified wording throughout the Clinical Indications, changing ‘temporomandibular dysfunction’ to ‘temporomandibular disorders.’ Revised medically necessary criteria for surgical intervention specific to the age requirement for documented radiograph proof of completion of skeletal growth as follows: “Completion of skeletal growth for individuals under age 18 with long bone x-ray or serial cephalometrics showing no change in facial bone relationships over the last three to six month period (Note: individuals age 18 and older do not require this documentation).” Alphabetized, formatted and reordered document Clinical Indications without additional revisions to the document criteria. Updated Description, Coding, Discussion, Definitions, and References.



Updated Coding section with 10/01/2010 ICD-9 changes.



MPTAC review. Updated References and Coding.



MPTAC review. Updated Discussion and References.



MPTAC review. Updated References and Coding to include 01/01/2008 CPT changes.



MPTAC review. Updated References.



MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number



Anthem, Inc.




Anthem Northeast (Maine)



TMJ (Temporomandibular Joint Syndrome) Benefit Detail

Anthem Midwest



Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ, Craniomandibular Disorder (CMD)

WellPoint Health Networks, Inc.


Clinical Guideline

Temporomandibular Joint Arthroplasty



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