Number: 019
Revised

Subject: Temporomandibular Disorders

Reviewed:  May 6, 2020

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made our decisions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

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.

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
Revised: August 26, 2008; November 16, 2009; January 20, 2011; September 23, 2013; September 29, 2014; May 6, 2020

Medical Clinical Policy Bulletin #0028  
March 10, 2020: This CPB has been revised to state that the following are considered experimental and investigational for the treatment of TMJ disorders: autologous blood injection, dextrose prolotherapy, disc plication, laser capsulorrhaphy, and sclerotherapy.

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.