CurrentAnthemPolicy 07-800

Occlusal Orthotic Device

Defines clinical guidance for placement of occlusal orthotic devices for temporomandibular disorders (TMD) and orofacial pain under the medical plan; notes device may not be covered under dental plan and is not to be used for obstructive sleep apnea.

Policy Summary

PayerAnthem

PolicyOcclusal Orthotic Device

Policy CodePolicy 07-800

Change TypeMinor editorial refinements

Effective DateJan 1, 2025

Next Review Date

Key ActionProvider must submit a narrative and patient records with rationale for treatment to support medical necessity for the occlusal orthotic device.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to description and clinical indications; intent unchanged.

Publish Date 01/01/2025 and recording of policy as Dental Clinical Policy.

2Primary Indications (TMD, Orofacial Pain)

1Explicit Exclusion (Obstructive Sleep Apnea)

2CDT Codes Listed

Coverage Summary

scope_summary: Defines clinical guidance for placement of occlusal orthotic devices for temporomandibular disorders (TMD) and orofacial pain under the medical plan; notes device may not be covered under dental plan and is not to be used for obstructive sleep apnea.

Key Facts

Policy Number07-800

Effective Date2025-01-01

Last Review2024-10-31

StatusCURRENT (Revised)

Primary IndicationsTreatment of temporomandibular disorders (TMD); control of orofacial pain

Explicit ExclusionNot to be used for treatment of obstructive sleep apnea

CDT Codes ListedD7880 (occlusal orthotic device, by report); D7881 (occlusal orthotic device adjustment)

Medical Necessity Criteria

Covered when ALL of the following are met:

ALL of the following

Narrative and records: Narrative and patient records with rationale for treatment are provided.
Indication is treatment of temporomandibular disorder (TMD) or control of orofacial pain (device intended to reposition or stabilize the jaw).
Exclusion - OSA: Device is NOT being used for treatment of obstructive sleep apnea.
Use for obstructive sleep apnea is explicitly excluded.
Benefit verification: Confirm member's coverage under medical plan; device may not be a covered service under the dental plan.
Coverage depends on member's contract benefits.

Provider Actions

Documentation Required

Provide narrative and patient records

Provider must submit a narrative and patient records with rationale for treatment to support medical necessity for the occlusal orthotic device.

D7880
D7881

Documentation Required

Confirm carrier and member benefits

Verify member contract benefits and confirm whether the occlusal orthotic device is covered under the medical plan rather than the dental plan prior to providing the service.

Denial Risk

Exclusion for obstructive sleep apnea

Claims for occlusal devices used to treat obstructive sleep apnea are not supported by this policy and are at risk for denial.

Background & Definitions

Occlusal orthotic devices (occlusal splints) are appliances used to reposition or stabilize the jaw for treatment of temporomandibular disorders (TMD) and to control orofacial pain. These appliances are considered medical in nature when used for TMD and are typically covered under medical plans rather than dental plans. The devices may not be covered under the dental plan. Occlusal orthotic devices are explicitly not to be used for treatment of obstructive sleep apnea.

Term	Definition
Occlusal Orthotic Device
An appliance used to reposition or stabilize the jaw for treatment of TMD or to control orofacial pain (also referred to as occlusal splint).
TMD
Temporomandibular disorders affecting the jaw joint and muscles controlling jaw movement.

Evidence & References

Evidence References:

Reference 1: Dylina TJ. 'The Basics of Occlusal Splint Therapy' Dentistry Today 7/1/2002

Reference 2: Crout Danny K. 'Anatomy of an Occlusal Splint' General Dentistry March/April 2017

Reference 3: CDT 2025 Current Dental Terminology, American Dental Association

Revision History

10/31/2024editorial