GENERAL INFORMATION
It is an expectation that all patients receive care/services from a licensed clinician.  All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
Imaging can assist in the diagnosis of TMJ dysfunction (TMD) when history and physical examination findings are equivocal. .

Policy
INDICATIONS FOR TEMPOROMANDIBULAR JOINT (TMJ) MRI
Evaluation of Temporomandibular Joint Dysfunction (TMD)
Suspected Internal Joint Derangement (1,2,3)

• Persistent symptoms of facial or jaw pain, restricted range of motion, pain and/or noise with TMJ function (i.e., chewing) AND
• Conservative therapy with a trial of anti-inflammatory AND behavioral modification* has been unsuccessful for at least four (4) weeks
• *Behavioral modification may include patient education, self-care, cognitive behavior therapy, physical therapy, and occlusal devices. 

Note: X-ray should be the initial study if there is recent trauma, dislocation, malocclusion, or dental infection

Evaluation of Juvenile Idiopathic Arthritis (JIA) (2,4,5)

Abnormal Initial X-ray or Ultrasound (2)
Additional imaging is needed.

Pre-Operative Evaluation (6)
Candidates for orthognathic surgery

Post-Operative Evaluation (7)
Follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Further Evaluation of Indeterminate Findings on Prior Imaging
Unless follow-up is otherwise specified within the guideline:

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Rationale/Background
Temporomandibular Join Dysfunction (TMD)
Temporomandibular joint (TMJ) dysfunction causes pain and dysfunction in the jaw joint and muscles controlling jaw movement. Symptoms may include jaw pain, masticator muscle stiffness, limited movement or locking of the jaw, clicking or popping in jaw joint when opening or closing the mouth, and a change in how the upper and lower teeth fit together. The cause of the condition is not always clear but may include acute or chronic trauma to the jaw or temporomandibular joint, e.g., grinding of teeth, clenching of jaw, or impact in an accident. Osteoarthritis or rheumatoid arthritis may also contribute to the condition.

TMD Etiologies
Etiologies of TMJ dysfunction (TMD) include intra-articular (intracapsular) and extra-articular (extracapsular pathology). Intra-articular (intracapsular pathology), such as disc 
displacement and coexisting osteoarthritis or degenerative joint disease, is considered the most common cause of serious TMJ pain and dysfunction and the most likely to be treated surgically. Extra-articular (extracapsular pathology) includes musculoskeletal (bone, masticatory muscles and tendons) and central nervous system/peripheral nervous system.(8)

TMD Imaging
Imaging can assist in the diagnosis of TMD when history and physical examination findings are equivocal. The initial study should be plain radiography (transcranial and transmaxillary views) or panoramic radiography when there is recent trauma, dislocation, malocclusion, or dental infection.(3) Ultrasound is an inexpensive and easily performed imaging modality that can also be used to evaluate the TMJ.(2) CT is useful to evaluate the bony structures of the TMJ when there is suspicion of bony involvement (i.e., fractures, erosions, infection, invasion by tumor, as well as congenital anomalies).(2) Magnetic resonance imaging (MRI) has the highest sensitivity, specificity, and accuracy in the evaluation of temporomandibular joint dysfunction and provides tissue contrast for visualizing the soft tissue and periarticular structures of the TMJ.

TMD Conservative Care
Conservative care for TMD includes patient education, self-care, behavioral modification, cognitive behavioral therapy/biofeedback, medication, physical therapy, and occlusive devices. Medications includes NSAIDS and muscle relaxants (for spasms) and in chronic cases benzodiazepines or antidepressants. 

There is lack of high-quality evidence and uncertainty about the effectiveness of manual therapy and therapeutic physical therapy in treating TMJ dysfunction.(9)

The use of occlusive splints is thought to alleviate some of the degenerative forces on the TMJ which may be helpful in patients with bruxism or nocturnal teeth clenching. Preferred devices are unclear from the literature and dental consultation is required.(3) In systematic reviews, there has been short-term benefit observed from splinting but no clear role in the overall long-term treatment of TMD patients.(10,11)

Contraindications and Preferred Studies
● Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on 
trimester)
● Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non-compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

References 

1. Jeon K, Lee C, Choi Y, Han S. Analysis of three-dimensional imaging findings and clinical symptoms in patients with temporomandibular joint disorders. Quantitative imaging in medicine and surgery. 2021; 11: 1921-1931. 10.21037/qims-20-857.  
2. Gharavi S, Qiao Y, Faghihimehr A, Vossen I. Imaging of the Temporomandibular Joint. Diagnostics (Basel, Switzerland). 2022; 12: 10.3390/diagnostics12041006. 
3. Gauer R, Semidey M. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015; 91: 378-86. 
4. Schmidt C, Ertel T, Arbogast M, Hügle B, Kalle T. The Diagnosis and Treatment of Rheumatoid and Juvenile Idiopathic Arthritis of the Temporomandibular Joint. Deutsches Arzteblatt international. 2022; 119: 47-54. 10.3238/arztebl.m2021.0388. 
5. Bollhalder A, Patcas R, Eichenberger M, Müller L, Schroeder-Kohler S et al. Magnetic Resonance Imaging Followup of Temporomandibular Joint Inflammation, Deformation, and Mandibular Growth in Juvenile Idiopathic Arthritis Patients Receiving Systemic Treatment. The Journal of rheumatology. 2020; 47: 909-916. 10.3899/jrheum.190168. 
6. Krishnan B, Parida S. Preoperative Evaluation and Investigations for Maxillofacial Surgery. Bonanthaya, K., Panneerselvam, E., Manuel, S., Kumar, V.V., Rai, A. (eds) Oral and Maxillofacial Surgery for the Clinician. Springer, Singapore. 2021; 11 - 24. 10.1007/978-981-15-1346-6_2. 
7. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015; 27: 109-24. 10.1016/j.coms.2014.09.008. 
8. American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Cranio. 2003; 21: 68-76. 
9. Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Phys Ther. 2016; 96: 9-25. 10.2522/ptj.20140548. 
10. Kuzmanovic Pficer J, Dodic S, Lazic V, Trajkovic G, Milic N. Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects. PLoS One. 2017; 12: e0171296. 10.1371/journal.pone.0171296. 
11. Zhang C, WuJ Y, Deng D, He B, Tao Y et al. Efficacy of splint therapy for the management of temporomandibular disorders: a. Oncotarget. 2016; 7: 84043-84053. 10.18632/oncotarget.13059.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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