Temporomandibular Joint Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial Botox injections. Mehta and colleagues note that temporomandibular disorders (TMD) are associated with substantial morbidity, affecting quality of life and work productivity, and that the goals of TMD management are to alleviate pain and to improve jaw function and quality of life. The authors further explain that standard noninvasive management includes self-care and education, physical therapy, occlusal splints, behavioral therapy, and adjunctive pharmacotherapy, while for patients with TMD symptoms refractory to noninvasive management, treatment options may include trigger point muscle injections, botulinum toxin injections, intra-articular injections, or, in some patients, surgery such as arthrocentesis, arthroscopy, arthroplasty, or temporomandibular joint (TMJ) reconstruction.…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for orthognathic surgery (reconstruction of midface, LeFort, bilateral sagittal split osteotomy, segmental osteotomy, with genioglossus advancement, septoplasty, excision inferior turbinate, oral surgical splint, virtual surgical planning, and maxillomandibular fixation). As noted by the Researchers“The surgical correction of maxillofacial skeletal deformities includes the reconstructive procedures that correct deformities of the maxilla, mandible, facial skeleton, and associated soft tissue structures.” Further, the AAOMS noted that “The principal goal for surgical correction of the maxillofacial skeletal deformity is to create or restore normal form, function, and health, while minimizing potential negative short-term and long-term sequelae.” On review of the r…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. There is a lack of controlled studies, single or double-blind, that prove the efficacy of botulinum toxin used in the treatment of temporomandibular joint disorders. Temporomandibular joint disorders represent a complex and multifaceted set of conditions affecting the jaw joint and muscles controlling jaw movement. The treatment for temporomandibular joint disorders varies, ranging from conservative therapies to surgical interventions. Botulinum toxin, primarily known for its use in cosmetic procedures, has been explored as a treatment for temporomandibular joint disorders. The use of botulinum toxin in temporomandibular joint disorders is predicated on its ability to reduce muscle activity, thereby alleviating pain and dysfunction.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement and authorization and coverage for Botulinum toxin (Botox) injections. The enrollee has diagnoses of gingival recession, limited range of motion, temporomandibular joint (TMJ) disorders, sleep-related bruxism, muscle spasm, atypical facial pain, myofascial pain, headache and dystonia. The enrollee has been treated for painful bruxism, which has been causing persistent facial pain, dystonia, and headaches. She has demonstrated improvement, indicating the treatments have been effective in alleviating pain due to bruxism. The enrollee notes she has nighttime teeth clenching, in addition to bruxism with no evidence she grinds her teeth. Most of the pain she has experienced from clenching her teeth, which is involuntary, occurs during the day.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving temporomandibular joint disorder, then check the rights and deadlines that apply to your plan.