TMJ dysfunction – non-invasive physical therapies policy (046)

Number: 046
Update

Subject: Temporomandibular Joint (TMJ) Dysfunction – Non-Invasive Physical Therapies

Reviewed: July 11, 2022

Important note

This Clinical Policy Bulletin expresses Aetna's determination of 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 this 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 Aetna’s opinion 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 benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers 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 the CMS coverage database

Policy

Aetna considers physical therapy (PT) medically necessary when prescribed by a practitioner, qualified to prescribe physical therapy according to state law, in order to significantly improve, develop or restore physical functions lost or impaired as a result of a disease, injury or surgical procedure, and the following criteria are met:
 

• The member’s participating dentist has determined that the member’s condition can improve significantly based on physical measures (for example, active range of motion (AROM), strength, function or subjective report of pain level) within one month of the date that therapy begins and/or the therapy services proposed must be necessary for the establishment of a safe and effective maintenance program that will be performed by the member without ongoing skilled therapy services. These services must be proposed for the treatment of a specific illness or injury.
• The PT services are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that a member’s condition will improve significantly in a reasonable and generally predictable period of time.
• PT services must be ordered by a dentist and performed by a duly licensed and certified Dentist or if applicable, PT provider. All services provided must be within the applicable scope of practice for the provider in his/her licensed jurisdiction where the services are provided.
• The services provided must be of the complexity and nature to require that they are performed by a licensed dentist, professional therapist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. As dentists are not licensed as physical therapists, they may not directly supervise physical therapy assistants.
• PT must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating dentist in accordance with applicable state laws and regulations. The PT plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.

Physical therapy in asymptomatic persons or in persons without an identifiable clinical TMJ condition is considered not medically necessary. Physical therapy in persons whose condition is neither regressing nor improving is considered not medically necessary. Once therapeutic benefit has been achieved, or a home exercise and diet program could be used for further gains, continuing supervised physical therapy is not considered medically necessary.

Coverage is only available in dental plans that cover TMJ services.  In those plans, the available physical therapy benefit is defined by 25 treatment sessions covered per year.

Claim submission requirements:
 

Physical therapy should be provided in accordance with an ongoing, written plan of care. The written plan of care will determine the medical necessity of treatment and must include:
 

• The diagnosis along with the date of onset or exacerbation of the disorder/diagnosis
• A reasonable estimate of when the goals will be reached
• Long-term and short-term goals that are specific, quantitative and objective
• Physical therapy evaluation
• The frequency and duration of treatment
• The specific treatment techniques and/or exercises to be used in treatment
• Signatures of the patient's attending dentist and physical therapist if applicable

The plan of care should be ongoing, (for example, updated as the patient's condition changes), and treatment should demonstrate reasonable expectation of improvement as defined below:
 

• Physical therapy services are considered medically necessary only if there is a reasonable expectation that physical therapy will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time.
• The patient should be reevaluated regularly (at least monthly), and there should be documentation of progress made toward the goals of physical therapy.
• The treatment goals and subsequent documentation of treatment results should specifically demonstrate that physical therapy services are contributing to such improvement.

Codes

D9130 - temporomandibular joint dysfunction – non-invasive physical therapies 

Review dates

Original policy: August 24, 2018

Update: April 2, 2020; August 11, 2021; July 11 2022

The above policy is based on the following references:

American Dental Association. CDT 2022: Dental Procedure Codes

Aetna Medical CPB 0325 – Physical Therapy  

Copyright 2022 American Dental Association. All rights reserved. 

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental 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 health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.