Download Temporomandibular Disorders

REVIEW REQUEST FOR
Temporomandibular Disorders
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-09
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/12/2011
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Nonsurgical Treatments for Temporomandibular Disorders
Request is for nonsurgical treatment for a temporomandibular disorder which includes: (Check all that apply)
Reversible, removable, intraoral appliances such as removable splints
Pharmacologic therapy (i.e., analgesics, anti-inflammatory drugs, and muscle relaxants)
Physical therapy
Therapeutic injections
Biofeedback
Dental devices for joint range of motion or for development of muscles used in jaw function
Dental prostheses (e.g., dentures, implants)
Dental restorations (e.g. bridgework, crowns)
Electrogalvanic stimulation (EGS)
Iontophoresis
Occlusal equilibration
Bite adjustment
Irreversible occlusion therapy
Orthodontic services such as braces and application of a mandibular advancement repositioning device
Other: (please list)
Surgical Procedure for Temporomandibular Disorders
Request is for surgical procedure(s) to treat a temporomandibular disorder: (Check all that apply)
Arthrocentesis
Arthroscopic surgery
Manipulation for reduction of fracture or dislocation
TMJ arthroplasty with FDA approved prosthetic implants
TMJ arthroplasty with prosthetic implants NOT approved by the FDA
REVIEW REQUEST FOR
Temporomandibular Disorders
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-09
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/12/2011
Open surgical procedure when TMD is the result of congenital anomalies, disease or trauma: (Check all that apply)
Arthroplasty
Condylectomy
Meniscus plication
Disc plication
Disc removal
Other: (please list)
Dental implants
Dental restorations
Extraction of wisdom teeth
Orthodontic services
Other: (please list)
The individual is under age 18.
The individual is 18 years of age or older.
The individual has documented temporomandibular joint internal derangement or other structural joint disorder
The individual has completed skeletal growth (for individuals under age 18) with long bone x-ray or serial cephalometrics
show no change in facial bone relationships over the last 3-6 month period (Note: individuals age 18 and older do not
require this documentation)
Computed tomography (CT),magnetic resonance imaging (MRI), or x-ray of the temporomandibular joint documents
joint pathology (e.g., arthritis, bone cyst, fracture, meniscal abnormality, tumors)
The individual has temporomandibular joint pain or a clinically significant functional impairment that is not due to
maxillary/mandibular skeletal deformity and is refractory to at least six months of non-surgical treatment. Please specify
treatments given: (Check all that apply)
Behavioral therapy
Pharmacologic therapy (i.e., analgesics, nonsteroidal anti-inflammatory drugs, muscle relaxants)
Physical therapy
Reversible, removable, intraoral appliances such as removable splints
Therapeutic injections
Other: (please list)
Other: (please list)
Diagnostic Testing for Temporomandibular Disorders
Request is to diagnose or evaluate a temporomandibular disorder with: (Check all that apply)
Computerized mandibular scan (intended to document deviations in occlusion and muscle spasm by recording
muscle activity related to mandibular movement or positioning)
Intra-oral tracing or gothic arch tracing (intended to document deviations in jaw positioning)
Electromyography (including percutaneous or surface electrode methods)
Kinesiography
Somatosensory testing/neuromuscular junction testing
Sonogram (ultrasonic Doppler auscultation)
Standard dental x-ray
Thermography
Transcranial or lateral skull x-ray
Other: (please list)
REVIEW REQUEST FOR
Temporomandibular Disorders
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-09
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/12/2011
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.