CommercialPrior AuthHigh impact
Temporomandibular Disorders (CPB 0028, reviewed 2026-03-12)
Aetna·Oral & Maxillofacial Surgery, Physical Therapy, Pain Management·Medical Policy
Effective date
Mar 12, 2026
We identified it
Aug 14, 2026
Summary
Aetna updated its Temporomandibular Disorder (TMD/TMJ) medical policy (CPB 0028) effective March 12, 2026. The policy reaffirms coverage criteria for diagnostic testing, non-surgical management (including oral splints with strict frequency limits), physical therapy, pharmacological management, and surgical procedures. Key billing requirement: TMJ surgery requests require prior authorization review by Aetna's Oral and Maxillofacial Surgery unit; non-surgical management must include 3+ months of documented treatment before surgery is considered medically necessary.
Action Required
REQUIREMENTS: By March 12, 2026 (or immediately if patients are currently being treated): (1) Billing team must implement mandatory prior authorization process for ALL TMJ surgical procedures in Aetna systems—claims submitted without prior auth review documentation will be denied. (2) Update encounter forms and billing checklists to require providers to document 3-6 months of non-surgical management history before submitting any TMJ surgery authorization request. (3) For intra-oral appliances (splints): enforce 1 appliance per patient limit in billing system; allow only adjustments within 6 months of initial placement without additional review; flag adjustments after 6 months or >4 total adjustments for medical review before processing payment. (4) For prolonged appliance use (>6 months): require individual case review documentation before billing. (5) Deny claims for replacement of lost/missing/stolen appliances; process other replacements/repairs only after medical necessity review. (6) Ensure all TMJ diagnostic imaging requests include required documentation: problem-specific history via Aetna TMD Questionnaire, physical exam findings, and imaging reports before submitting for coverage determination. (7) Front desk/authorization staff should escalate all TMJ surgical precertification requests directly to Aetna's Oral and Maxillofacial Surgery Patient Management Unit per policy requirements. Failure to obtain prior authorization or submit required documentation will result in claim denials.