Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/18/1995 Title: TMJ Coverage
Revision Date: 12/01/2017 Document: BI231:00
CPT Code(s): 21125, 21127, 21137-21139, 21141-21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179-21184, 21188, 21193, 21194-21196, 21198, 21199, 21206, 21208-21210, 21215, 21230, 21235, 21240, 21242-21249, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 70300, 70310, 70320, 70328, 70330, 70332, 70336, 70355
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    As a member, you may or may not have a benefit for coverage of Temporomandibular Joint (TMJ) problems. Please consult your coverage documents for clarification.

2)    When diagnosis and treatment of TMJ problems are covered services, these services require preauthorization.

3)    Some plans cover only surgical treatments for TMJ, such as joint replacement or reconstruction.  Such plans would not cover non-surgical treatments such as therapy or mouth guards.  Non-surgical treatments (self-help techniques and medical treatments) need to have been tried and failed before surgical treatments can be authorized.  If your physician or dentist is recommending treatment for TMJ problems, please make sure that you understand what kind of treatment is being recommended.

4)    Dental work such as orthodontics, crowns, implants, inlays, on-lays, or bridgework or dentures, is not covered under the medical benefit even if done primarily for treatment of TMJ conditions. 


Medical Statement

TMJ problems may or may not be covered under plans administered by QualChoice. This includes both treatment and diagnostic studies.  When services for diagnosis and treatment of TMJ problems are covered, all such services require preauthorization.  Please consult your patient’s coverage documents or call customer service for further clarification.

 

The diagnosis and assessment of TMJ may include such tests as x-rays, MRI studies, arthrograms and the creation of models of the jaws so that the treating physician (or dentist) can determine the dynamics of chewing.

 

The treatment of TMJ may range from simple splints and bite blocks to significant surgical rearrangements of the jaws. Some plans provide payment for splints but not for surgery.  Some plans provide coverage only for surgical treatment of TMJ.

 

Coverage for TMJ surgery may be more restricted than coverage for other dental-related problems, such as:

 

Coverage for care of traumatic injuries to sound natural teeth. Some services are covered during such treatment that would not be covered under any other circumstance (such as in the case of TMJ problems).

 

Coverage for surgery to produce normal anatomic alignment in cases of cleft palate. Here again, some services are covered that would not be covered under any other circumstance (such as in the case of TMJ problems).

 

Codes Used In This BI:

70300

X-ray exam of teeth

70310

X-ray exam of teeth

70320

Full mouth x-ray of teeth

70328

X-ray exam of jaw joint

70330

X-ray exam of jaw joints

70332

X-ray exam of jaw joint

70336

Magnetic image jaw joint

70355  

Panoramic X-ray of jaw

21125

Augmentation lower jaw bone

21127

Augmentation lower jaw bone

21137

Reduction of forehead

21138

Reduction of forehead

21139

Reduction of forehead

21141

Reconstruct midface lefort

21142

Reconstruct midface lefort

21143

Reconstruct midface lefort

21145

Reconstruct midface lefort

21146

Reconstruct midface lefort

21147

Reconstruct midface lefort

21150

Reconstruct midface lefort

21151

Reconstruct midface lefort

21154

Reconstruct midface lefort

21155

Reconstruct midface lefort

21159

Reconstruct midface lefort

21160

Reconstruct midface lefort

21172

Reconstruct orbit/forehead

21175

Reconstruct orbit/forehead

21179

Reconstruct entire forehead

21180

Reconstruct entire forehead

21181

Contour cranial bone lesion

21182

Reconstruct cranial bone

21183

Reconstruct cranial bone

21184

Reconstruct cranial bone

21188

Reconstruction of midface

21193

Reconstr lwr jaw w/o graft

21194

Reconstr lwr jaw w/graft

21195

Reconstr lwr jaw w/o fixation

21196

Reconstr lwr jaw w/fixation

21198

Reconstr lwr jaw segment

21199

Reconstr lwr jaw w/advance

21206

Reconstruct upper jaw bone

21208

Augmentation of facial bones

21209

Reduction of facial bones

21210

Face bone graft

21215

Lower jaw bone graft

21230

Rib cartilage graft

21235

Ear cartilage graft

21240

Reconstruction of jaw joint

21242

Reconstruction of jaw joint

21243

Reconstruction of jaw joint

21244

Reconstruction of lower jaw

21245

Reconstruction of jaw

21246

Reconstruction of jaw

21247

Reconstruct lower jaw bone

21248

Reconstruction of jaw

21249

Reconstruction of jaw

21255

Reconstruct lower jaw bone

21256

Reconstruction of orbit

21260

Revise eye sockets

21261

Revise eye sockets

21263

Revise eye sockets

21267

Revise eye sockets

21268

Revise eye sockets

21270

Augmentation cheek bone

21275

Revision orbit facial bones

21280

Revision of eyelid

21282

Revision of eyelid

21295

Revision of jaw muscle/bone

21296

Revision of jaw muscle/bone


Reference

Addendum.

1.     Effective 01/01/17: Added x-ray code and description.

 

2.     Effective 12/01/2017: Added step care requirements to try/fail self-help measures before medical treatments and medical treatments before surgical treatments.


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.