806 KAR 17:090. Preauthorization requirements for coverage of temporomandibular joint disorder and evaluation of medical necessity for treatment of craniomandibular jaw disorder.

 

      RELATES TO: KRS 304.17-319, 304.18-0365, 304.32-1585, 304.38-1937

      STATUTORY AUTHORITY: KRS 304.2-110, 304.32-250, 304.38-150

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110 provides that the Executive Director of Insurance may make reasonable administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code. KRS 304.32-250 provides that the Executive Director of Insurance may make reasonable administrative regulations he deems necessary for the proper administration of KRS Chapter 304.32. KRS 304.38-150 provides that the Executive Director of Insurance may make reasonable administrative regulations deemed necessary for the proper administration of KRS Chapter 304.38. This administrative regulation requires health insurers, nonprofit hospital, medical-surgical, dental, and health service corporations, and health maintenance organizations which require preauthorization for coverage of temporomandibular joint disorder to use a uniform preauthorization request form and to follow certain standards in determining whether treatment of craniomandibular jaw disorder is medically necessary.

 

      Section 1. Definition. "Insurer" means an insurer, a nonprofit hospital, medical-surgical, dental, and health service corporation, or a health maintenance organization.

 

      Section 2. If an insurer requires preauthorization of nonsurgical treatment for coverage of temporomandibular joint disorder, it shall require the provider of treatment to submit a properly completed temporomandibular joint disorder (TMJ) nonsurgical treatment preauthorization request form (1993), incorporated by reference and available for inspection and copying at the Kentucky Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601-1847, 8 a.m. to 4:30 p.m. (ET), weekdays.

 

      Section 3. If an insurer requires preauthorization of surgical treatment for coverage of temporomandibular joint disorder, it shall require the provider of treatment to submit a properly completed temporomandibular joint disorder (TMJ) surgical treatment preauthorization request form (1993), incorporated by reference and available for inspection and copying at the Kentucky Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601-1847, 8 a.m. to 4:30 p.m. (ET), weekdays.

 

      Section 4. In evaluating the information obtained pursuant to Sections 2 and 3 of this administrative regulation, insurers shall utilize the following:

      (1) ICD-9-CM Diagnostic Codes for Temporomandibular Disorders.

      (a) Intracapsular.

      1. 719.68 Other symptoms referable to joint/deviation in form (repetitive joint noise).

      2. 718.38 Disc displacement with reduction/recurrent dislocation of joint/dislocation (open lock).

      3. 718.28 Disc displacement without reduction/pathological dislocation (closed lock).

      4. 728.5 Hypermobility syndrome.

      5. 727.09 Synovitis (previously used term: capsulitis; discitis, retrodiscitis, arthritis).

      6. 716.98 Capsulitis/arthropathy, unspecified.

      7. 715.38 Osteoarthrosis.

      8. 715.98 Osteoarthritis/arthropathy, unspecified.

      9. 714.9 Polyarthritides/unspecified inflammatory polyarthropathy.

      10. 718.58 Fibrous ankylosis of joint/bony ankylosis of joint.

      (b) Extracapsular.

      1. 729.1 Myofascial pain/myalgia and myositis, unspecified.

      2. 728.81 Myositis/myositis.

      3. 728.85 Spasm/spasm of muscle.

      4. 728.89 Reflex splinting/muscle contracture/muscle hypertrophy.

      (2)(a) Diagnostic studies. Appropriate radiographic studies shall be done based on symptomatology.

      1. ADA00330 Panoramic x-rays.

      2. ADA00322 Radiograph tomogram survey (TMJ corrected angle tomogram).

      3. ADA00321 TMJ transorbital/transcranial projection.

      4. 70370 TMJ lateral transcranial/transpharyngeal x-rays (lateral skull).

      5. ADA00290 Radiograph anterior-posterior projection of skull/head.

      6. 70486 Computerized axial tomography, maxillofacial area; without contrast material.

      7. 21116 Injection procedure for temporomandibular joint arthrography.

      8. 70333 ADA00320 Temporomandibular joint arthrography, complete procedure.

      9. ADA00470 Mounted diagnostic dental study models.

      10. 20550 Injection, trigger points.

      11. 70328 70330 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral, bilateral (these codes shall not be used. Use one (1) of above codes).

      (b) Surgery performed. 20605 Arthrocentesis, aspiration, or injections; intermediate joint (e.g., temporomandibular).

      (3) Nonsurgical treatment. This subsection contains standards for submitting claims for temporomandibular joint nonsurgical treatment modalities. These claims shall be prepared using the procedure codes listed below. All codes are CPT codes unless otherwise identified. One (1) initial office visit is allowed within one (1) plan of treatment. Thereafter, the office visit(s) are included in the diagnostic studies and treatment listed below.

      (a) 99201 Office and other outpatient medical services, new patient; brief service.

      (b) 99215 Comprehensive history and physical examination of patient: Medical history, observations as to pain, pain analysis questionnaire, muscle and TMJ analysis and palpation, occlusal analysis, cranial nerve analysis, cervical analysis, TMJ noises, and mandibular range of motion measurements.

      (c) Diagnostic studies. Not every TMJ patient requires an x-ray. Appropriate radiographic studies shall be done based on symptomatology.

      1. ADA00330 or 70355 Panoramic x-rays.

      2. ADA00322 Radiographic tomogram survey (TMJ corrected angle tomogram).

      3. ADA00321 TMJ transorbital/transcranial projection.

      4. 70370 TMJ lateral transcranial/transpharyngeal x-ray (lateral skull).

      5. ADA00290 Radiograph, anterior-posterior projection of skull/head.

      6. ADA00470 Mounted diagnostic models if necessary. Benefits may not provide for cephalometric x-rays for TMJ disorders. Benefits may not provide for casts and unmounted study models for diagnosis. These services may be part of the splint therapy.

      7. 20550 Injection, trigger points.

      (d) Treatment provided. ADA07880 or ADA 09941.

      1. Splint therapy which does not result in any permanent alteration of the occlusion. Splint therapy includes post-insertion, follow-up care, and adjustments.

      a. Hard acrylic splint, orthotic, etc.

      b. Soft rubber mouth guard.

      2. 20605 ADA07870.

      a. Arthrocentesis, aspiration, or injections; intermediate joint (e.g., temporomandibular).

      b. Physical therapy.

      c. Benefits may not provide for behavioral modification, biofeedback, stress management, or services of a psychologist.

      (4) Surgical treatment. This subsection contains standards for submitting claims for reimbursement for temporomandibular joint surgical treatment modalities. These claims shall be prepared using the procedure codes listed below. All codes are CPT codes unless otherwise identified. One (1) initial office visit is allowed with one (1) plan of treatment. Thereafter, the office visits are included in diagnostic studies and surgeries listed below.

      (a) 99201 Office and other outpatient medical services, new patient; brief service.

      (b) 99215 Comprehensive history and physical examination of patient. This includes the medical/dental history, observations as to pain, pain analysis questionnaire, muscle and TMJ analysis and a palpation, occlusal analysis, cranial nerve analysis, cervical analysis, TMJ noises, and mandibular range of motion measurements.

      (c) Only one (1) of the following listed codes is acceptable for the surgical procedures performed on the same date of service. If bilateral procedures are performed, code each procedure separately on the claim. This may require the listing of one (1) procedure code twice.

      1. 29800 Arthroscopy, temporomandibular joint, diagnostic, with or without biopsy, includes irrigation and debridement (separate procedure).

      2. 29804 Arthroscopy, temporomandibular joint surgical (includes all arthroscopic reconstruction arthroplasties of the temporomandibular joint, resection of adhesions and joint lavage, etc.).

      3. 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft).

      4. 21242 Arthroplasty, temporomandibular joint, with allograft (interpositional material such as silastic to replace the meniscus).

      5. 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement (operative report shall be included with claim).

      6. 21010 Arthrotomy, temporomandibular joint (this code is part of 21240, and 21243. Charges may not be accepted for 21010).

      7. Physical therapy.

 

      Section 5. This section contains standards for evaluation of claims for craniomandibular (jaw or orthognathic) disorders for medical necessity. To evaluate appropriately a claim for correction of a craniomandibular (jaw or orthognathic) disorder, the existence of a skeletal disorder shall be documented. Any craniomandibular (jaw, orthognathic) maldevelopment that is not correctable with conventional orthodontic treatment, yielding a stable and functional post-treatment occlusion without worsening the patient's original aesthetic condition, shall be a covered surgical procedure.

      (1) Indications for craniomandibular (jaw, orthognathic) surgery shall include evidence of at least one (1) of the following:

      (a) Physical evidence of musculoskeletal, dento-osseous, or soft tissue deformity.

      (b) Imaging evidence of musculoskeletal, dento-osseous, or soft tissue deformity:

      1. Deviation form cephalometric norms; or

      2. Other imaging disclosure of abnormality.

      (c) Malocclusion deviating from a normal occlusal relationship that cannot reasonably be corrected by nonsurgical means (e.g., orthodontics or prosthetics).

      (d) Inability to open or close the jaws adequately.

      (2) The following data shall be submitted so that claims may be evaluated appropriately:

      (a) A narrative of the patient's presenting clinical condition with appropriate ICD-9 diagnostic codes (subsection (3) of this section) and appropriate CPT codes for treatment (subsection (4) of this section).

      (b) Study models with appropriate bite registration.

      (c) Intra-oral and extra-oral photographs.

      (d) Cephalometric x-ray.

      (e) The data required in paragraphs (b), (c), and (d) of this subsection may be substituted with appropriate paper documentation using current computer imaging systems that have the ability to photograph all necessary information including appropriate views of study models. This allows the submission of paper documentation rather than the bulky study models and bite registrations.

      (3) The following ICD-9 code shall be used in determining whether treatment of craniomandibular (jaw, orthognathic) disorder is medically necessary:

      (a) 524.0 Major anomalies of jaw size.

      1. Hyperplasia.

      2. Hypoplasia (maxillary, mandibular).

      3. Macrognathism (maxillary, mandibular).

      4. Micrognathism (maxillary, mandibular).

      5. Macrogenia (maxillary, mandibular).

      6. Microgenia (maxillary, mandibular).

      (b) 524.1 Anomalies of relationship of jaw to cranial base.

      1. Asymmetry of jaw.

      2. Prognathism (maxillary, mandibular).

      3. Retrognathism (maxillary, mandibular).

      (c) 524.2 Anomalies of dental arch relationship.

      1. Crossbite (anterior, posterior).

      2. Disto-occlusion

      3. Mesio-occlusion.

      4. Midline deviation.

      5. Open bite (anterior, posterior).

      6. Overbite (excessive): deep, horizontal, or vertical.

      7. Overjet.

      8. Posterior lingual occlusion of mandibular teeth.

      9. Soft tissue impingement.

      (d) 524.5 Dentofacial functional abnormalities.

      1. Abnormal jaw closure.

      2. Malocclusion due to abnormal swallowing, mouth breathing, and tongue, lip, or finger habits.

      (e) 526.89 Unilateral condylar hyperplasia or hypoplasia of mandible.

      (f) 754.0 Hemifacial atrophy or hypertrophy.

      (4) The following CPT codes shall be used in determining whether treatment of craniomandibular (jaw or orthognathic) disorder is medically necessary:

      (a) Mandible.

      1. Mandibular sagittal split osteotomy.

      a. Without rigid fixation: right 21195; left 21195.

      b. With rigid fixation: right 21196; left 21196.

      2. Mandibular ramus osteotomy (Horizontal, Vertical, C or L).

      a. Without graft: right 21193; left 21193.

      b. With graft: right 21194; left 21194.

      3. Mandibular segmental osteotomy: 21198.

      4. Genioplasty (Augmentation, sliding): 21120.

      5. Genioplasty (Reduction, sliding): 21121.

      (b) Maxillae.

      1. LeForte I maxillary osteotomy.

      a. Single piece: 21144.

      b. Single piece with graft: 21145.

      2. LeForte I maxillary osteotomy (segmental).

      a. Two (2) or more pieces: 21146.

      b. Three (3) or more pieces: 21147.

      3. LeForte II.

      a. Without graft: 21150.

      b. With graft: 21151.

      4. LeForte III.

      a. Without graft: 21154.

      b. With graft: 21155.

      (c) Osteoplasty (Facial bones).

      1. Augmentation: 21208.

      2. Reduction: 21209.

      (d) Cotreatment.

      1. Assistant surgeon: Modifier 80.

      2. Cosurgeon: Modifier 62. (19 Ky.R. 2353; Am. 20 Ky.R. 79; eff. 7-12-93; TAm eff. 8-9-2007.)