CurrentAnthemPolicy 07-800

Occlusal Orthotic Device

Policy governing review and dental-plan coverage considerations for placement of occlusal orthotic devices (occlusal splints) primarily used for temporomandibular disorders and orofacial pain; intended for providers submitting dental benefits under the plan.

Policy Summary

PayerAnthem

PolicyOcclusal Orthotic Device

Policy CodePolicy 07-800

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionSubmit a narrative and patient records with rationale for treatment when requesting review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Narrative + recordsrequired documentation for review

D7880, D7881example procedure codes shown

01/01/2024policy publish date

Coverage Criteria for Occlusal Orthotic Devices

General Coverage and Review Criteria

Covered when ALL of the following are met

Documentation: A narrative and patient records with rationale for treatment are provided for review.

Required for review.

Standards of Care: Service meets generally accepted standards of dental practice as defined by peer-reviewed dental literature, specialty society recommendations, and views of recognized dentists in the clinical area.

Plan review assesses alignment with standards of care and that the service is effective for the patient’s condition.

Contractual Benefits: The service is a covered benefit under the member’s contract; inclusion in this policy does not guarantee coverage or reimbursement.

Coverage is contingent on the member's contract and plan determination; medical vs dental plan responsibility may apply.

Policy Summary

PayerAnthem

PolicyOcclusal Orthotic Device

Policy CodePolicy 07-800

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionSubmit a narrative and patient records with rationale for treatment when requesting review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Review, Documentation, and Billing Guidance

Prior Authorization

Review and documentation requirement

Prior review and documentation are required before coverage can be determined. Providers must submit a clinical narrative and supporting patient records that explain the need for an occlusal orthotic device and demonstrate how the requested service meets accepted standards of dental care and the member's contract benefits.

Informational codes: D7880, D7881

Note

Providers should include source details in the submitted documentation to support the clinical rationale (e.g., diagnostic findings, prior treatments tried, and expected benefit). Failure to provide sufficient source documentation may result in delayed review or denial.

Documentation Required

Required documentation

Submit a detailed narrative and complete patient records that clearly state the clinical indications, prior conservative treatments, treatment goals, and how the occlusal orthotic meets the criteria. Documentation must provide a rationale tying the requested procedure to the member’s clinical needs.

Denial Risk

Coverage contingent on contract and standards

Coverage is contingent on the member’s contract and on meeting accepted dental practice standards. Even when documentation is provided, services may be denied if they are not a covered benefit under the member's contract or if they do not meet generally accepted standards of dental care.

Key Definitions

Occlusal Orthotic Device — definition

DefinitionA dental appliance used to reposition or stabilize the jaw for treatment of temporomandibular disorders (TMD) and to control orofacial pain.

Typical coverage contextOften considered medical in nature and may not be a covered service under the dental plan; typically covered under medical plans.

Scope of useIntended to reposition or stabilize the jaw for TMD and to control orofacial pain; NOT to be used for treatment of obstructive sleep apnea.

Relation to standards of careUse should align with generally accepted standards of dental practice based on peer-reviewed literature, specialty society recommendations, and views of recognized dentists.

Documentation implicationPlacement and review require documentation demonstrating alignment with accepted standards and medical necessity for the patient.

Background

Occlusal orthotic devices are removable dental appliances designed to reposition or stabilize the mandible and/or maxilla to address temporomandibular disorders (TMD) and associated orofacial pain. They are used as a non‑surgical, conservative treatment option intended to reduce pain, limit parafunctional activity, and improve jaw function. Because these appliances address a medical condition and are evaluated against clinical standards, their review includes assessment of documentation demonstrating the device meets generally accepted standards of dental practice—including evidence from peer‑reviewed dental literature, specialty society recommendations, and the views of recognized practitioners—and an accompanying narrative and patient records are required for plan review.

OpenPayer

Occlusal Orthotic Device

Coverage Criteria for Occlusal Orthotic Devices

Relevant Codes and Diagnosis References

Provider Review, Documentation, and Billing Guidance

Key Definitions

Background

D7880	occlusal orthotic device, by report
D7881	occlusal orthotic device adjustment