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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.