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Jaw Motion Rehabilitation Systems
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This policy governs coverage and medical necessity for jaw motion rehabilitation systems (e.g., Therabite, OraStretch) primarily for treating mandibular hypomobility caused by radiation in head and neck cancer patients and addresses other indications considered experimental/investigational. It applies to Aetna benefit determinations.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indication
Covered when ALL of the following are met
Experimental / Investigational (Not Medically Necessary) indications
Not covered (considered experimental and investigational) when ANY of the following indications are claimed
List is not all-inclusive per policy.
Some benefit plans treat jaw stretch devices as over‑the‑counter equipment when they are available without a prescription. In those plans the devices may be excluded from coverage. Check the member’s specific benefit plan description to determine whether the device is covered or excluded.
Published clinical reports on off‑label uses of jaw motion rehabilitation systems are limited and preliminary. Case series and small case reports (for example, studies of TheraBite in Duchenne muscular dystrophy, spinal muscular atrophy, and combined use with pentoxifylline plus vitamin E for scleroderma) suggest possible improvements in passive or active range of motion for some patients, but the authors uniformly state that further investigation is needed before these indications can be considered established.
Use of jaw motion rehabilitation systems for indications listed under the policy’s Experimental and Investigational section is considered not medically necessary because the peer‑reviewed evidence is insufficient and effectiveness has not been established for those indications.
Coding
| 95851 | Range of motion measurements and report (separate procedure); each extremity, (excluding hand) or each trunk section (spine). |
| 97110 | Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. |
| 97535 | Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes. |
| C76.0 | Malignant neoplasm of head, face and neck. |
| M26.69 | Other specified disorders of temporomandibular joint. |
| Z92.3 | Personal history of irradiation. |
| R25.2 | Cramp and spasm [trismus]. |
| M26.601 | Temporomandibular joint disorders (range listed in policy). |
| G71.01 | Duchenne or Becker muscular dystrophy. |
| Q75.4 | Mandibulofacial dysostosis [Treacher Collins Syndrome]. |
Provider Actions and Billing
Denial Triggers / Coverage Risk
Denial triggers for non-covered indications: Jaw motion rehabilitation systems (eg, Therabite, OraStretch) are considered experimental/investigational and are likely to be denied when used for indications listed in the policy’s Experimental and Investigational section (examples include closed lock treatment; facial/oral burns; improvement of TMJ range of motion in Duchenne muscular dystrophy or spinal muscular atrophy; mandibular coronoid hyperplasia; maxillofacial trauma after surgical intervention; non-surgical TMJ dysfunction; orofacial pain; post‑surgical TMJ rehabilitation; rehabilitation following facial trauma; stroke; Treacher Collins syndrome; trismus outside of radiation‑induced cases; and other indications where evidence is insufficient).
- Devices are considered experimental/investigational for listed indications and likely denied if submitted for these non‑covered uses.
- Check member benefit plan exclusions; some plans exclude jaw stretch devices as over‑the‑counter equipment without a prescription.
Billing / Coding Notes
Prior authorization and coding: HCPCS codes E1700, E1701, and E1702 are billed when selection criteria in the policy are met. Use the relevant ICD‑10 diagnosis codes that support mandibular hypomobility due to radiation (for example, C76.0, M26.69, Z92.3) when submitting claims. Review benefit plan details for any plan‑level exclusions that would preclude coverage.
Step Therapy / Prior Authorization
Step therapy and prior authorization requirements: No step therapy requirements are described in the policy excerpt. The document does not specify additional prior authorization requirements beyond ensuring that selection criteria are met and that the indication is radiation‑induced mandibular hypomobility.
- No step therapy required as per provided sections.
- No explicit additional prior authorization processes specified in the excerpt; verify plan‑specific PA rules if applicable.
Provider Documentation
Provider documentation actions: Document clinical history linking mandibular hypomobility to prior head and neck radiation, include diagnosis codes supporting radiation‑induced hypomobility, and retain records of conservative therapy tried (eg, oral opening exercises, tongue blade stacking, therapist‑guided stretching) where relevant. The policy excerpt contains no further explicit provider action requirements.
- Document radiation history and diagnosis codes (eg, Z92.3; C76.0; M26.69).
- Record prior conservative therapies attempted when applicable (conventional stretching exercises, home exercise programs).
- No additional provider actions explicitly required in the provided excerpt.
Background and Evidence Summary
Mandibular hypomobility refers to a reduction in mandibular range of motion that commonly follows head and neck radiation therapy. Radiation can cause scarring and soft‑tissue contraction around the jaw; the severity of hypomobility is related to radiation dose, treated volume, and patient factors. Conservative approaches to stretching scar tissue include oral opening exercises, tongue‑blade stacking, continuous passive motion, and use of custom mechanical devices such as the TheraBite. Small clinical reports demonstrate that mechanical stretching with devices like the TheraBite can increase passive and, in some cases, active range of motion in affected patients, but the evidence base outside radiation‑induced cases is limited.
Definitions
Revision History
Next scheduled policy review date set to 04/25/2024.
Policy last reviewed on 06/07/2023.
Policy effective date established as 05/04/2000.
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