Temporomandibular Disorders — CPB 0028 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0028 governing temporomandibular disorder (TMD) and temporomandibular joint (TMJ) coverage, effective September 26, 2025. Here's what billing teams need to do before claims go out the door.

This update to the Aetna TMJ coverage policy affects a wide range of CPT codes — from arthrocentesis (CPT 20605, 20611) and open joint surgery (CPT 21010, 21050, 21060) to reconstructive procedures like mandibular rami reconstruction (CPT 21194, 21195, 21196) and midface Le Fort osteotomies (CPT 21141–21160). The policy also explicitly flags dozens of codes — including platelet-rich plasma injections (CPT 0232T), transcranial magnetic stimulation (CPT 90867–90869), and various physical therapy modalities — as non-covered or experimental under CPB 0028 Aetna. If your practice bills for TMJ surgery or TMD treatment to Aetna patients, this policy sets the rules for what gets paid and what gets denied.

Quick Reference: Aetna CPB 0028 TMJ Policy Change (2025)

Aetna TMJ Coverage Criteria and Medical Necessity Requirements 2025

The Aetna TMJ coverage policy has a firm gating requirement: no TMJ surgery request moves forward without review by Aetna's Oral and Maxillofacial Surgery patient management unit. This isn't optional, and skipping it will produce a claim denial regardless of how well-documented the clinical case is.

To satisfy medical necessity review, you need to submit four things together. First, a problem-specific history using the Aetna Temporomandibular Disorder Questionnaire. Second, a physical examination report. Third, TMJ radiographs or diagnostic imaging reports — meaning CPT 70300, 70310, 70320 (standard dental radiographs) or CPT 70487, 70488 (maxillofacial CT with contrast) need to be in the record. Fourth, the proposed treatment plan.

The medical necessity standard here also requires documented evidence of three to six months of non-surgical management before surgery becomes approvable. That documentation must describe the nature of the non-surgical treatment, the results, and the specific clinical findings from that treatment. Vague notes won't pass. Aetna's reviewers want specifics — what was tried, what happened, and what findings support moving to surgery.

This structure mirrors how Aetna handles other surgical specialties where conservative care is a prerequisite. The real issue for billing teams is the documentation burden on the clinical side. If the chart doesn't support the full three-to-six-month conservative care history, prior authorization will be denied before billing even enters the picture.

Aetna TMJ Exclusions and Non-Covered Indications

This is where CPB 0028 gets expensive for practices that haven't audited their charge capture. A large block of codes in this policy — spanning regenerative injections, neuromodulation, physical therapy modalities, and surgical reconstruction procedures — carry a "not covered / experimental" designation under the groups labeled "Bio-oxidative ozone therapy, Magnetic neurostimulator, MIRO."

Platelet-rich plasma injection (CPT 0232T) is not covered. Autologous white blood cell concentrate injection (CPT 0481T) is not covered. Transcranial magnetic stimulation — CPT 90867, 90868, and 90869 — is not covered for TMD. Hypnotherapy (CPT 90880) is not covered.

On the surgical side, genioplasty codes (CPT 21120–21123), mandibular augmentation (CPT 21125–21127), Le Fort I through III reconstruction (CPT 21141–21160), and mandibular rami reconstruction (CPT 21194–21196) all carry the experimental designation. This matters because some of these procedures appear in treatment plans alongside covered TMJ procedures. Bundling a non-covered reconstruction code into a claim with a covered arthrotomy will create problems at adjudication.

Physical therapy modalities are broadly excluded: electrical stimulation unattended (CPT 97014), diathermy (CPT 97024), infrared (CPT 97026), ultraviolet (CPT 97028), electrical stimulation manual (CPT 97032), iontophoresis (CPT 97033), ultrasound (CPT 97035), and Hubbard tank (CPT 97036) are all in the not-covered group. Needle EMG codes for cranial nerve-supplied muscles — CPT 95867, 95868, and 95887 — are also excluded.

If your practice or an affiliated PT department bills these codes for TMD patients, stop and verify payer before submitting.

Coverage Indications at a Glance

Aetna TMJ Billing Guidelines and Action Items 2025

CPT, HCPCS, and ICD-10 Codes for Temporomandibular Disorders Under CPB 0028

Covered CPT Codes (When Selection Criteria Are Met)

Note: The full policy lists 59 additional covered CPT codes. Review the complete CPB 0028 policy at app.payerpolicy.org/p/aetna/0028. for the full covered code set.

Not Covered / Experimental CPT Codes

These codes fall under the "Bio-oxidative ozone therapy, Magnetic neurostimulator, MIRO" exclusion group in CPB 0028.

Note: The full policy includes 149 total HCPCS codes. Review the complete code set at the CPB 0028 source document.