CurrentBlue Cross Blue Shield - WisconsinPolicy 07-800

Occlusal Orthotic Device (2023 Policy) PDF. Opens in a new window

Defines the plan's review guidance for occlusal orthotic devices (occlusal splints) used to treat temporomandibular disorders (TMD) and orofacial pain, and clarifies dental vs medical plan applicability and contract-based coverage determination.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyOcclusal Orthotic Device (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 07-800

Change TypeAnnual review (11/11/2022)

Effective Date

Next Review Date

Key ActionPrior to review, submit a narrative and patient records with rationale for treatment to support medical/dental necessity.

SourceLink

POLICY UPDATE CHANGES

Policy revised with annual review on 11/11/2022.

Initial policy published 12/02/2020 (version history).

2CDT codes listed

Coverage Summary

Defines the plan's review guidance for occlusal orthotic devices (occlusal splints) used to treat temporomandibular disorders (TMD) and orofacial pain. Coverage is mixed: TMD appliances are often considered medical in nature and typically covered under medical plans, while dental plan coverage depends on the member's contract and whether services meet generally accepted standards of dental practice.

Key Metadata

Billing & Coding

CDT codes (informational)mixed

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

ICD-10-CM DiagnosesICD-10

No codes listed

Code listings are provided for informational purposes only and do not guarantee coverage or reimbursement. Determine coverage by referring to the member's contract benefits at the time of service and submit a narrative with patient records to support medical/dental necessity.

Provider Actions & Requirements

Documentation Required

Submit narrative and patient records

Prior to review, submit a narrative and patient records with rationale for treatment to support medical/dental necessity.

Submit records and rationale prior to review.

Billing Rule

Verify benefit and contract applicability

Determine coverage by referring to the member's contract benefits at time of service because inclusion of codes is informational and does not guarantee coverage or reimbursement.

D7880
D7881

Denial Risk

Not for obstructive sleep apnea

Claims for occlusal orthotic devices for treatment of obstructive sleep apnea are not appropriate under this dental policy and may be denied or considered medical benefit instead.

Background & Definitions

Occlusal orthotic devices (splints) are used to reposition or stabilize the jaw for the treatment of temporomandibular disorders (TMD) and to control orofacial pain. The policy notes these devices may not be covered under the dental plan because TMD appliances are often considered medical in nature and typically covered under medical plans. For dental coverage, services must meet generally accepted standards of dental practice (based on peer-reviewed dental evidence, specialty society recommendations, views of recognized dentists in the clinical area, and other credible sources).

References: Dylina TJ (2002); Crout DK (2017); CDT 2023

Definitions

Generally accepted standards of dental practiceStandards based on peer-reviewed dental evidence, specialty society recommendations, views of recognized dentists in the clinical area, and other relevant credible sources.