DESCRIPTION
Arthroscopy of the temporomandibular joint (TMJ) is a diagnostic and/or therapeutic procedure for visualizing and treating the pathologic changes associated with TMJ disorders. A trocar is introduced into the joint by means of an external puncture in the neck region. Either a local or general anesthetic is used. An arthroscope that has a light source and video imaging attachment is then inserted. A second puncture is sometimes performed at an adjacent site when additional instrumentation is necessary for therapy.
POLICY
Arthroscopy of the temporomandibular joint for the treatment of intra-joint pathology is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Arthroscopy of the temporomandibular joint for purely diagnostic purposes with no treatment is considered not medically necessary.
MEDICAL APPROPRIATENESS
Arthroscopy of the temporomandibular joint for the treatment of intra-joint pathology is considered medically appropriate if ALL of the following criteria are met:
Intra-joint pathology diagnosis is confirmed by x-ray, arthrogram or MRI
The individual has ANY ONE of the following conditions:
Internal derangement
Hypomobility, secondary to intra-joint adhesions
Synovitis
Degenerative joint disease
Hypermobility, resulting in painful subluxation or dislocation
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Arthroscopy of the temporomandibular joint (TMJ) may be contraindicated in cases of:
Skin infections
Possible tumor seeding
Other circumstances unique to the individual
SOURCES
American Society of Temporomandibular Joint Surgeons (ASTJS). (2000, April). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Retrieved November 5, 2003 from http://www.astmjs.org/guidelines.html.
BlueCross BlueShield Association, Medical Policy Reference Manual. (1.2003). Temporomandibular joint dysfunction (2.01.21). Retrieved June 26, 2009 from BlueWeb.
ECRI Institute. Health Technology Assessment Information Service. Evidence Reports. (2001, March). Temporomandibular articular disorders: selected treatments. Retrieved June 26, 2009 from ECRI Institute.
Hobeiche, J., Salameh, Z., Tashkandi, E. & AlmasK. (2008). Arthroscopy vs. open-joint surgery for the management of internal derangement of the temporomandibular joint: a retrospective study comparing female subjects from two centers. Journal of Contemporary Dental Practice, 9 (3), 48-55.
Schiffman, E.L., Look, J.O., Hodges, J.S., Swift, J.Q., Decker, K.L., Hathaway, K.M., et al. (2007). Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. Journal of Dental Research, 86 (1), 58-63.
ORIGINAL EFFECTIVE DATE: 3/1988
MOST RECENT REVIEW DATE: 9/10/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.