D0330 — Panoramic image
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For pharmacologic trials (e.g., propranolol): baseline and follow-up facial pain index (FPI) calculations and documentation of adverse events.
- Patient records reflecting a complete history of 3 to 6 months of non-surgical management, describing the nature of the non-surgical treatment, the results, and the specific findings associated with that treatment, must be submitted with TMJ surgery requests.
- Proposed treatment plan must be submitted for review of TMJ surgery requests.
- TMJ surgery precertification/review must include submission of a problem-specific history (i.e., Aetna Temporomandibular Disorder Questionnaire) and physical examination.
Key Coverage Criteria
- Use of imaging modalities (US, CT, MRI) for diagnosis and procedural guidance (e.g., US-guided TMJ injections; CT-guided injections in select pediatric JIA cases).
- Relaxation therapy, electromyographic biofeedback and cognitive behavioral therapy (CBT) (medically necessary).
- For plans that cover treatment of temporomandibular disorder (TMD) and temporomandibular joint (TMJ) dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit.
- Diagnostic Testing (medically necessary): Examination including a history, physical examination, muscle testing, range of motion measurements and psychological evaluation as necessary.
- Diagnostic X-rays - a single panoramic X-ray of the jaws is considered medically necessary for the initial evaluation of TMJ disorders. Additional X-rays are considered medically necessary if surgery is contemplated.
- Ultrasonography for detection of internal derangements of the temporomandibular joint (medically necessary).
1 Active Policy
AETNA-CPB-0028 — Temporomandibular Disorders
Related Codes
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