CurrentBlue Cross Blue Shield - MainePolicy 07-800

Occlusal Orthotic Device

Policy governing review and clinical guidance for placement of occlusal orthotic devices (dental occlusal splints) and how dental benefit determination is applied; affects providers submitting requests for occlusal orthotic device services under the plan.

Policy Summary

PayerBlue Cross Blue Shield - Maine

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 for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Requires narrative & patient recordsDocumentation prerequisite for review

D7880, D7881Listed procedure codes

11/01/2023Policy last reviewed

01/01/2024Policy publish date

Coverage Criteria

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Occlusal orthotic devices and appliances used for temporomandibular disorders (TMD) are often considered medical in nature and therefore may not be a covered service under the dental plan. Such services are typically covered under medical plans rather than dental benefits; coverage depends on the nature of the condition and the member's plan contract.

Provider Actions and Requirements

Documentation Required

Review and documentation requirement — narrative and patient records with rationale required per contract. Submit a detailed narrative explaining the clinical indication for the occlusal orthotic device and include pertinent patient records (e.g., dental/medical history, diagnostic findings, imaging, clinical exam notes, prior conservative treatments tried and responses). The narrative must explain why the device is medically/dentally necessary for this patient per the plan's contract and generally accepted standards of dental practice.

Required: narrative describing clinical indication and rationale
Required: relevant patient records (history, exam, imaging, prior treatments)
Explain why treatment meets generally accepted standards of dental practice and is not primarily cosmetic or for convenience
Note: occlusal orthotic devices for TMD may be considered medical in nature and could be covered under medical plans

Prior Authorization

Provider: submit clinical rationale and prior treatment history

Actionable provider guidance: Provide a concise clinical justification that ties the patient’s signs/symptoms and diagnostic findings to the proposed occlusal orthotic device. Include documentation of prior conservative therapies attempted (e.g., medications, physical therapy, splinting alternatives) and responses. Lack of sufficient narrative or records may result in denial or request for additional information.

Describe specific TMD-related symptoms and objective findings
List prior non-device treatments and outcomes
Attach copies of relevant imaging and clinical exam notes

Documentation Required

Submit narrative and patient records

Required documentation — submission of narrative and patient records with rationale for treatment. The submission should demonstrate that the requested service meets the plan contract standard of care and is the least costly option that properly addresses the patient’s condition. If the occlusal orthotic device is billed to the dental plan but the service is determined to be medical in nature, payment may be denied and coverage may be considered under the member's medical plan instead.

Narrative tying clinical findings to medical necessity
Patient records: history, exam, imaging, prior treatment documentation
Statement on why device is preferred over alternative, less costly options

Denial Risk

Coverage and Benefit Determination

Coverage subject to contract and plan benefits — benefit determination may deny payment if not covered under member's dental plan. The plan's determination of medical/dental necessity does not guarantee coverage; confirm member benefits and coordinate with medical plan when TMD treatment is judged medical in nature.

Verify member dental benefits prior to submission
If service determined medical, consider submitting to medical plan

Background

Occlusal orthotic devices (occlusal splints) are devices used to reposition or stabilize the jaw to treat temporomandibular disorders (TMD) and to control orofacial pain. The plan performs review of requests for these devices because contractual requirements require that dental services meet generally accepted standards of dental care. Because TMD and related appliances are frequently considered medical in nature, these devices may be covered under medical plans rather than the dental plan. Additionally, these devices are not indicated for treatment of obstructive sleep apnea.

Definitions and Standards

Definition — Occlusal Orthotic Devices (inv-12)

TermOcclusal Orthotic Devices

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

Coverage noteMay not be a covered service under the dental plan; TMD and these appliances are considered medical in nature and typically covered under medical plans.

Not indicated forObstructive sleep apnea — occlusal orthotic devices may not be used in the treatment of OSA.

Generally accepted standards of dental practice — sources (inv-13)

Evidence sourcesCredible scientific evidence published in peer‑reviewed dental literature generally recognized by the practicing dental community.

Specialty guidanceRecommendations and criteria from relevant dental specialty societies.

Clinical expert viewsThe views of recognized dentists practicing in the relevant clinical area.

Other credible factorsAny other relevant factors from credible sources used to define generally accepted standards of dental practice.

Revision History

2024-01-01policy_publishLatest

Policy published (Dental Clinical Policy).

2023-11-01last_review

Policy underwent last annual review.

2022-11-11annual_review

Annual review conducted by committee.

2021-10-30annual_review

Annual review conducted by committee.

2020-12-06annual_review

Annual review conducted by committee.

2020-12-02initial_release

Initial policy released.

Policy Summary

PayerBlue Cross Blue Shield - Maine

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 for review.

SourceLink

On This Page

OpenPayer

Occlusal Orthotic Device

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions and Standards

Revision History

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