Temporomandibular Joint Disorders - UHCprovider.com
Temporomandibular Joint Disorders Page 1 of 13 UnitedHealthcare Commercial Medical Policy Effective 03/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Medica l Policy Temporomandibular Joint Disorders Policy Number: 2022T0079GG Effective Date: March 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale ........................................ ............................... 1 Documentation Requirements ........................................ .............. 2 Definitions.
CT scans, and/or MRI Treating physician’s plan of care, including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit History of previous non -surgical and surgical treatment Outpatient Surgical Procedures – Site of Service 20552, 20553, 20605, 20606, 21010, 21070,
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