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07.08.03i, Medical and Surgical Treatment of Temporomandibular Joint Disorder
Effective date
Feb 26, 2024
Identified
Oct 29, 2026
Summary
Independence Blue Cross reissued its TMD policy on 10/28/2026 to communicate the Company's continuing position on medical and surgical treatment of temporomandibular joint disorder. The policy was previously effective 02/26/2024 with additions including condylectomy as medically necessary surgical treatment, updated criteria for procedures altering vertical dimension, and new CPT/ICD-10 codes. The most recent 10/28/2026 reissue contains no stated material changes beyond reaffirming the existing policy position.
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What to do
Action · 4 steps
01Already effective 02/26/2024: Verify whether the practice has implemented prior coverage updates including condylectomy as medically necessary surgical treatment, new CPT codes 21050 and 97799, and new ICD-10 diagnosis codes (M26.601, M26.602, M26.603, M26.609, M26.611, M26.612, M26.613, M26.619, M26.621).
02The 10/28/2026 reissue reaffirms the existing policy position for Independence Blue Cross Commercial plans.
03Confirm current applicability of medical necessity criteria for TMD treatments, including documentation requirements for biofeedback (up to 2–3 visits/week for 6–8 weeks), trigger point injection criteria, and surgical treatment prerequisites (refractoriness to medical therapy, clinically significant pain, mandibular malfunction, and radiologic confirmation of joint pathology).
04Check that billing system reflects the removal of HCPCS code D9940 (occlusal guard for bruxism) as of the 02/26/2024 effective date.
Codes mentioned
21050977999702497110971129712497140L8699D7880D7881D9942D9950M26.601M26.602M26.603M26.609M26.611M26.612M26.613M26.619M26.621
Original notice
07.08.03i, Medical and Surgical Treatment of Temporomandibular Joint Disorder
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
See all Independence Blue Cross changes →MA07.024g, Medical and Surgical Treatment of Temporomandibular Joint DisorderLowEffective Feb 26, 2024 · Medical Policy11.14.02s, Trigger Point InjectionsMediumEffective Apr 1, 2025 · PharmacyMA07.024g, Medical and Surgical Treatment of Temporomandibular Joint DisorderMediumEffective Feb 26, 2024 · Medical Policy07.08.03i, Medical and Surgical Treatment of Temporomandibular Joint DisorderMediumEffective Feb 26, 2024 · Medical PolicyBrowse every Independence Blue Cross change in the policy list
Related policy hubs
Independence Blue Cross policiesOral & Maxillofacial SurgeryPhysical TherapyDentistryPain ManagementCode 21050Code 97799Code 97024Code 97110Code 97112Code 97124Code 97140Code L8699Code D7880Code D7881Code D9942Code D9950Code M26.601Code M26.602Code M26.603Code M26.609Code M26.611Code M26.612Code M26.613Code M26.619Code M26.621