CPT

This policy addresses surgical treatment of temporomandibular disorders (TMD/TMJ) and certain nonsurgical modalities. Surgery is covered when there is radiographic evidence of TMJ internal derangement or other structural joint pathology (e.g., arthritis, fracture, meniscal abnormality, bone cyst, or tumor), and for individuals under 18, documented completion of skeletal growth by long-bone x‑ray or stable serial cephalometrics over 3–6 months. Surgery is not covered if these criteria are not met, and the following nonsurgical treatments are not medically necessary: electrogalvanic stimulation, jaw motion rehabilitation systems, and mandibular image‑guided rehabilitative orthopedics (MIRO Therapy).

"Surgical procedures areconsideredmedically necessaryfor the treatment of temporomandibular disorderswhen the following criteria are met (AandB):"

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