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Excellus BlueCross BlueShieldCommercial · Documentation · Bone & Joints (Orthopedic) · Orthopedics, Oral & Maxillofacial SurgeryHigh impact

Temporomandibular Joint Disorders (TMJD) 11.01.17

Effective date
May 15, 2026
Identified
Jun 20, 2026

Summary

Excellus BlueCross BlueShield policy 11.01.17 sets criteria for surgical treatment of temporomandibular joint disorders (TMJD), with a current effective date of May 15, 2026. Surgery requires a documented functional deficit, such as pain or other physical deficit that interferes with activities of daily living, or impaired physical activity such as loss of range of motion. It also requires at least six weeks of failed conservative treatment, with dates and duration for two or more of medication, corticosteroid injection, soft diet, behavioral therapy, or physical therapy, plus MRI or CT reports of the TMJ. Each surgery type has its own imaging and examination requirements. The January 22, 2026 annual review expanded the conservative treatment and surgical criteria, added diagnostic testing requirements, and made a functional deficit required for surgical treatment.

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What to do

Action · 7 steps
01Already effective May 15, 2026: Billing team should confirm that each TMJ surgery claim documents a functional deficit, either pain or other physical deficit that interferes with activities of daily living, or impaired physical activity such as loss of range of motion.
02Claims need documentation of at least six weeks of failed conservative treatment, with dates and duration for two or more of the following: medication, corticosteroid injection, dietary modification such as a soft diet, behavioral therapy, or physical therapy.
03Conservative therapy documentation is not required in the setting of recent trauma, dislocation, severe malocclusion, dental infection or abscess.
04Documentation must include MRI or CT reports of the TMJ.
05For arthrocentesis or arthroscopy (CPT 20605, 20606, 29804), imaging reports must confirm anterior disc displacement with or without reduction, disc adhesions, synovitis/capsulitis, or degenerative osteoarthritis, and physical exam findings must support the diagnosis.
06For open joint surgery (CPT 21010, 21050, 21060, 21070, 21240, 21242), documentation must show persistent pain despite previous arthroscopic surgery and imaging that confirms one of the listed findings.
07For TMJ replacement (CPT 21243), imaging must show alteration and degeneration at both the bone and disc level, the reduced oral aperture must be less than 35 mm, and prior surgeries (arthroscopy or open) must have failed.

Codes mentioned

20605206062980421010210502106021070212402124221243

Original notice

Temporomandibular Joint Disorders (TMJD) 11.01.17
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs

Excellus BlueCross BlueShield policiesOrthopedicsOral & Maxillofacial SurgeryCode 20605Code 20606Code 29804Code 21010Code 21050Code 21060Code 21070Code 21240Code 21242Code 21243

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