150.1 - Treatment of Temporomandibular Joint (TMJ) Syndrome
(Rev. 1, 10-01-03)
PASS memo Read.014
There are a wide variety of conditions that can be characterized as TMJ, and an equally wide variety of methods for treating these conditions. Many of the procedures fall within the Medicare program‟s statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (Â§1862(a)(1) of the Act). Other services and appliances used to treat TMJ fall within the Medicare program‟s statutory exclusion at 1862(a)(12), which prohibits payment â€śfor services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth....â€ť For these reasons, a diagnosis of TMJ on a claim is insufficient. The actual condition or symptom must be determined.
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