CurrentAnthemPolicy 09-400

Occlusal Guard Guidelines

Defines clinical indications, limitations, coding and dental policy guidance for occlusal guards (removable appliances for bruxism/clenching) and clarifies non-indications and documentation requirements. Applies to dental benefit determinations; member contract controls actual coverage.

Policy Summary

PayerAnthem

PolicyOcclusal Guard Guidelines

Policy CodePolicy 09-400

Change TypeRevised (annual review)

Effective DateJan 1, 2024

Next Review Date

Key ActionProvider must supply a narrative with rationale for treatment when requesting occlusal guard services.

SourceLink

POLICY UPDATE CHANGES

Policy status indicated as Revised with last review 11/01/2023 and publish date 01/01/2024.

5Key Indication Points Listed

6Not Indicated Uses Listed

16CDT Codes Provided (approx.)

Coverage Summary

This policy (Subject: Occlusal Guard; Policy # 09-400) defines clinical indications, limitations, coding and documentation requirements for removable dental occlusal guards used to manage bruxism/clenching. Effective date: 01/01/2024. Last review date: 11/01/2023. Applies to dental benefit determinations; actual coverage is subject to the member's contract benefits.

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Medically Appropriate Criteria

Medically Appropriate / Indications

Occlusal guards are considered necessary/appropriate when ALL of the following apply:

ALL of the following

Purpose is to protect natural teeth from enamel wear or damage due to bruxism or clenching (including when opposing dentition has porcelain or ceramic restorations)
Used to minimize tooth sensitivity caused by clenching or bruxism
May be appropriate to relieve occlusal stress following periodontal therapy
A narrative with rationale for treatment is provided
Partial arch occlusal guards: coverage is contract dependent (may not be covered)

Not Indicated / Exclusions

Occlusal guards are NOT indicated for any of the following:

ANY of the following

Treatment of temporomandibular disorders or myofascial pain dysfunction
Use as an athletic mouth guard
Use as an appliance intended for orthodontic tooth movement
Treatment of obstructive sleep apnea
Tooth whitening, fluoride delivery, or delivery of periodontal medicaments

General Coverage Note

ALL of the following

When any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also not covered or denied
Dental services must meet generally accepted standards of dental practice (see list in policy) to be considered covered

Coding (CDT / ICD-10)

CDT codes (informational list)mixed

D0320	temporomandibular joint arthrogram, including injection
D0321	other temporomandibular joint radiographic images, by report
D0330	panoramic radiographic images
D0470	diagnostic casts
D7880	occlusal orthotic device
D7881	occlusal orthotic device adjustment
D9130	temporomandibular joint dysfunction - non-invasive physical therapies
D9941	fabrication of athletic mouth guard
D9942	repair and/or reline of occlusal guard
D9943	occlusal guard adjustment

1–10 of 14

1/2

ICD-10 CM Diagnoses (reference)ICD-10

No codes listed

ICD-10 CM Diagnoses (reference)ICD-10

No codes listed

Provider Actions & Billing Rules

Documentation Required

Narrative rationale required

Provider must supply a narrative with rationale for treatment when requesting occlusal guard services. The narrative should explain the clinical reason for the appliance (for example, to protect teeth from bruxism or clenching, to minimize sensitivity, or to relieve occlusal stress after periodontal therapy) to support medical necessity.

Denial Risk

Non-covered when related to excluded indications

Claims for occlusal guards provided for the following excluded uses are not indicated and may be denied when billed for those purposes.

Treatment of temporomandibular disorders or myofascial pain dysfunction
Use as an athletic mouth guard
Use as an appliance intended for orthodontic tooth movement
Treatment of obstructive sleep apnea
Tooth whitening, fluoride delivery, or delivery of periodontal medicaments

Billing Rule

Contract-dependent coverage for partial arch

The partial-arch occlusal guard code is identified and coverage of partial arch occlusal guards may be contract dependent; confirm coverage under the member's contract at the time of service.

D9946

Documentation Required

Adhere to accepted dental standards

Services must meet generally accepted standards of dental practice to be considered appropriate and covered. This includes care based on peer-reviewed dental evidence, specialty society recommendations, and the views of recognized practicing dentists in the relevant clinical area.

Background & Evidence

Occlusal guards are removable dental appliances intended to minimize or eliminate the effects of bruxism or clenching that can cause excessive wear, fractures of natural teeth, or damage to restorations. They cover teeth to protect them from ongoing tooth-to-tooth contact.

Construction: occlusal guards may be fabricated intraorally in the dental office or by an outside laboratory and are made from rigid or semi-rigid materials. They may be full-arch or partial-arch devices; note that partial arch occlusal guards may be contract-dependent and not covered.

Distinct from other conditions/treatments: by definition occlusal guards are not appropriate treatments for temporomandibular disorders (TMD) or myofascial pain dysfunction, and they are not indicated for athletic protection, orthodontic tooth movement, obstructive sleep apnea, tooth whitening, fluoride delivery, or periodontal medicament delivery.

References cited include Wassell; Manfredini et al.; Lobbezoo et al.; the Cochrane review on pharmacotherapy for sleep bruxism; and Jagger on occlusal splints (see policy references).

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