MRI Temporomandiublar Joint (TMJ) - CAM 740

Description
Temporomandibular joint (TMJ) dysfunction causes pain and dysfunction in the jaw joint and muscles controlling jaw movement. Symptoms may include jaw pain, masticator muscle stiffness, limited movement or locking of the jaw, clicking or popping in jaw joint when opening or closing the mouth, and a change in how the upper and lower teeth fit together. The cause of the condition is not always clear but may include acute or chronic trauma to the jaw or temporomandibular joint, e.g., grinding of teeth, clenching of jaw, or impact in an accident. Osteoarthritis or rheumatoid arthritis may also contribute to the condition.

Etiologies of TMJ dysfunction (TMD) include intra-articular (intracapsular) and extra-articular (extracapsular pathology). Intra-articular (intracapsular pathology), such as disc displacement and coexisting osteoarthritis or degenerative joint disease, is considered the most common cause of serious TMJ pain and dysfunction and the most likely to be treated surgically. Extra-articular (extracapsular pathology) includes musculoskeletal (bone, masticatory muscles and tendons) and central nervous system/peripheral nervous system (ASTMJS, 2001).

Imaging can assist in the diagnosis of TMD when history and physical examination findings are equivocal. The initial study should be plain radiography (transcranial and transmaxillary views) or panoramic radiography when there is recent trauma, dislocation, malocclusion, or dental infection (Gauer, 2015). Ultrasound is an inexpensive and easily performed imaging modality that can also be used to evaluate the TMJ (Tu, 2018). CT is useful to evaluate the bony structures of the TMJ when there is suspicion of bony involvement (i.e., fractures, erosions, infection, invasion by tumor, as well as congenital anomalies) (Bag, 2014). Magnetic resonance imaging (MRI) has the highest sensitivity, specificity, and accuracy in the evaluation of temporomandibular joint dysfunction and provides tissue contrast for visualizing the soft tissue and periarticular structures of the TMJ.

Conservative care for TMD includes patient education, self-care, behavioral modification, cognitive behavioral therapy/biofeedback, medication, physical therapy, and occlusive devices. Medications include NSAIDS and muscle relaxants and in chronic cases, benzodiazepines, or antidepressants. There is lack of high-quality evidence and uncertainty about the effectiveness of manual therapy and therapeutic physical therapy in treating TMJ dysfunction (Armijo-Olivo, 2016). The use of occlusive splints is thought to alleviate some of the degenerative forces on the TMJ which may be helpful in patients with bruxism or nocturnal teeth clenching. The preferred devices are unclear from the literature and dental consultation is required (Gauer, 2015). In systematic reviews, there has been short-term benefit observed from splinting but no clear role in the overall long-term treatment of TMD patients (Ebrahim, 2012; Pficer, 2017).

Policy
TEMPOROMANDIBULAR JOINT (TMJ) MRI is considered MEDICALLY NESSARY for the follwing indications: 

For evaluation of temporomandibular joint dysfunction (TMD) with suspected internal joint derangement with both: (Bag, 2014; Gauer, 2015; Petscavage-Thomas, 2014)    

  • Persistent symptoms of facial or jaw pain, restricted range of motion, pain and/or noise with TMJ function (i.e., chewing)  AND
  • Conservative therapy with a trial of anti-inflammatory AND behavioral modification* has been unsuccessful for at least four (4) weeks

Note: X-ray should be the initial study if there is recent trauma, dislocation, malocclusion, or dental infection

* Behavioral modification includes patient education, self-care, cognitive behavior therapy, physical therapy, and occlusal devices. Muscle relaxants can be used for spasm.

For evaluation of Juvenile idiopathic arthritis (JIA) (Granquist, 2018, Petscavage-Thomas, 2014)

Abnormal initial x-ray or ultrasound needing additional imaging (Bag, 2014)

Pre-operative evaluation in candidates for orthognathic surgery

Post-Operative Evaluation 

  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY. 

References 

  1. Aiken A, Bouloux G, Hudgins P. MR imaging of the temporomandibular joint. Magn Reson Imaging Clin N Am. 2012 Aug;20(3):397-412. doi: 10.1016/j.mric.2012.05.002. Epub 2012 Jul 15. Review.
  2. American Society of Temporomandibular Joint Surgeons (ASTMJS). Guidelines for Diagnosis and Management of Disorders involving the Temporomandibular Joint and related Musculoskeletal Structures. http://astmjs.org/final%20guidelines-04-27-2005.pdf. Published 2001.
  3. Armijo-Olivo S, Pitance L, Singh V, et al. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: Systematic review and meta-analysis. Phys Ther. 2016; 96(1):9-25. doi:10.2522/ptj.20140548.
  4. Bag AK, Gaddikeri S, Singhal A, et al. Imaging of the temporomandibular joint: An update. World J Radiol. 2014; 6(8):567-582. http://doi.org/10.4329/wjr.v6.i8.567.
  5. 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 Aug; 143(8):847-57.
  6. Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015; 91(6):378-386. https://www.aafp.org/afp/2015/0315/p378.html.
  7. Granquist E. Treatment of temporomandibular joint in a child with juvenile inflammatory arthritis. Oral Maxillofac Surg Clin North Am. 2018 Feb; 30(1):97-107.
  8. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015 Feb; 27(1):109-24.
  9. Murphy MK, MacBarb RF, Wong ME, et al. Temporomandibular disorders: a review of etiology, clinical management, and tissue engineering strategies. Int J Oral Maxillofac Implants. 2013; 28(6):e393–e414. doi:10.11607/jomi.te20
  10. Petscavage-Thomas JM, Walker EA. Unlocking the jaw: Advanced imaging of the temporomandibular joint. Am J Roentgenol. 2014; 203(5):1047-1058.
  11. Pficer JK, Dodic S, Lazic V, et al. Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term
  12. Stoll ML, Guleria S, Mannion ML, et al. Defining the normal appearance of the temporomandibular joints by magnetic resonance imaging with contrast: A comparative study of children with and without juvenile idopathic arthritis. Pediatr Rheumatol Online J. 2018; 16(8).
  13. Tu KH, Chuang HJ, Lai LA, et al. Ultrasound Imaging for Temporomandibular Joint Disc Anterior Displacement. J Med Ultrasound. 2018;26(2):109–110. doi:10.4103/JMU.JMU_18_18.

Coding Section 

Code Number Description
CPT 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward     

11/02/2021

Annual review, updating direction for initial xray for clarity. Also adding not and updating description. 

11/01/2020 

Annual review, updating policy with verbiage related to TMD and juvenile idiopathic arthritis. Also updating background and references. 

11/26/2019

New Policy

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