Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 35-year-old female with temporomandibular joint dysfunction and associated head and neck pain. Treatment with physical therapy produced significant improvement in symptoms. The submitted evidence does not demonstrate that she has been treated with a combination of dental occlusal splinting, analgesics and physical therapy. Orthotic splinting and occlusal equilibration has not been performed and the patients symptoms have recurred.A request has been made for authorization and coverage for an electromyography (EMG). The Health Plan has denied the request on the basis that EMG is considered investigational in this setting.The use of surface EMG in this clinical setting is unproven and would add no useful information or therapy that cannot be obtained by the usual methods of careful physical diagnosis and combined treatment (e.g., splint, analgesics and physical therapy). It is not necessary to employ EMG to obtain an acute and effective dental occlusal orthotic splint. Therefore, I have determined that the requested EMG is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 35-year-old female with temporomandibular joint (TMJ) dysfunction consistent with symptoms presented. Her provider has recommended use of electromyography (EMG). The Health Plan has denied coverage for an EMG on the basis it is considered investigational for evaluation of the patients medical condition.The use of EMG in the diagnosis and treatment of TMJ dysfunction is in fact documented and useful in carrying out the treatment of TMJ. Use of EMG in this case is medically warranted to properly construct a TMJ orthotic appliance, which is necessary to treat the patient. Other modalities are not likely to be as beneficial as use of EMG in this case. Therefore, I have determined that the requested EMG is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 3: The patient is a 35-year-old woman who states that she has moderate generalized, occipital and temporal headaches on the left side since February 2003. The patient has been diagnosed by her dentist with temporomandibular disorder, bilateral muscle spasms, cephalgia, and cervicalgia. The patients provider has recommended an electromyography (EMG) for evaluation of the patients condition. The use of surface electromyography (EMG) for the diagnosis and monitoring of temporomandibular disorders (TMD) was reviewed by Lund, et al. and Baba, et al. Both articles critically reviewed studies evaluating EMG use and found that in studies that found EMG levels to be elevated in TMD patients, the examiners were not blinded, the patient groups were not defined exactly, and the controls were not matched to the subjects. The only study that had matched controls for bruxisms found no difference in resting EMG levels between patients and non-symptomatic bruxers. In two well-controlled studies it was shown there was no difference in the resting EMG levels between painful and pain free sides of TMD patients. The review articles concluded EMG has a very low diagnostic value for TMD patients and has not been shown to be better than the use of pain scale rating or questionnaires. Based upon the information set forth above, I have determined that the requested EMG is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.