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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

June 2018

Updates to TMJ Prior Authorization Policy


Effective for dates of service beginning Aug. 1, 2018, Harvard Pilgrim is updating our commercial Temporomandibular Joint Disorders Medical Review Criteria to require prior authorization for the following additional CPT codes:

  • 21453 — Closed treatment of mandibular fracture with interdental fixation
  • 21461 — Open treatment of mandibular fracture; without interdental fixation
  • 21462 — Open treatment of mandibular fracture; with interdental fixation
  • 21465 — Open treatment of mandibular condylar fracture
  • 21470 — Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints
  • 21255 — Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

The following codes will remain on the policy and continue to require prior authorization:

  • 21085 — Oral surgical splint
  • 21010 — Arthrotomy, tempomandibular joint
  • 21060 — Meniscectomy, partial or complete, tempomandibular joint (separate procedure)
  • 21193 — Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
  • 21240 — Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
  • 21242 — Arthroplasty, temporomandibular joint, with allograft
  • 21243 — Arthroplasty, temporomandibular joint, with prosthetic joint replacement
  • 29804 — Arthroscopy, temporomandibular joint, surgical

Harvard Pilgrim also updated the surgical treatment criteria to include the additional requirements that the member: be at least 18 years of age (or have documentation confirming complete bone growth) and have had at least 6 months of non-surgical treatment that failed to relieve symptoms.

Additionally, under the updated policy an initial consultation by an oral surgeon to evaluate TMJ symptoms (one per lifetime, including exam and panoramic x-ray) may be covered.

For complete information, please refer to the updated Temporomandibular Joint Disorders Medical Review Criteria.

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Robert Farias,
Senior Vice President, Corporate Network Strategy

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