ModifiedBlue Cross Blue Shield - WisconsinPolicy 07-800

Occlusal Orthotic Device (2022 Policy) PDF. Opens in a new window

Defines clinical/dental review guidance for occlusal orthotic devices (occlusal splints) used to reposition or stabilize the jaw for temporomandibular disorders (TMD) and control orofacial pain; explains dental review standards and that devices may be medical-plan covered or excluded from dental benefits depending on contract.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyOcclusal Orthotic Device (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 07-800

Change TypeRevised

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionSubmit a narrative and patient records with rationale for treatment when requesting review for an occlusal orthotic device.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised; last review date 10/30/2021 and publish date 01/01/2022.

2CDT codes listed

1Required documentation items (narrative & records)

0Allowed for obstructive sleep apnea

Coverage Summary

Defines clinical/dental review guidance for occlusal orthotic devices (occlusal splints) used to reposition or stabilize the jaw for temporomandibular disorders (TMD) and to control orofacial pain. Dental review is performed to ensure services meet generally accepted standards of dental practice and requires documentation. Coverage of these devices depends on the member's contract and dental plan exclusions; some TMD appliances may be considered medical in nature and are typically covered under medical plans.

Provider Actions & Documentation

Documentation Required

Narrative and patient records required

Submit a narrative and patient records with rationale for treatment when requesting review for an occlusal orthotic device.

Affected codes: D7880, D7881

Denial Risk

Coverage subject to member contract and plan type

Claims for occlusal orthotic devices may be denied or redirected if the device is considered medical in nature (TMD) and covered under medical plans or excluded by the dental contract; device use for obstructive sleep apnea is not allowed.

Note: Device use for obstructive sleep apnea is not allowed and claims may be denied or redirected if covered under medical plans or excluded by the dental contract.

Background, Evidence & Definitions

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

Dental review follows the plan's definition of services that meet generally accepted standards of dental practice: services provided by a Dentist exercising prudent clinical judgment; appropriate in type, frequency and extent; effective for the patient's dental injury or disease; not primarily for convenience; not cosmetic; and not more costly than an alternative service. The plan's review is performed due to contractual requirements that benefits meet these specified standards, and a determination of dental necessity does not guarantee the service is a covered benefit under the dental plan.

Coding listed for informational purposes includes CDT codes D7880 (occlusal orthotic device, by report) and D7881 (occlusal orthotic device adjustment). Inclusion of codes does not imply coverage; refer to the member's contract to determine benefit applicability.

Standards used in the dental clinical policy include credible scientific evidence in peer-reviewed dental literature, specialty society recommendations/criteria, and the views of recognized practicing dentists in the relevant clinical area.

Require a narrative and patient records with rationale for treatment when submitting for review of an occlusal orthotic device.

References include Dylina TJ, Dentistry Today 2002 and Crout DK, General Dentistry 2017.

Evidence: References: Dylina TJ, 'The Basics of Occlusal Splint Therapy,' Dentistry Today 7/1/2002; Crout Danny K., 'Anatomy of an Occlusal Splint,' General Dentistry March/April 2017.

Generally accepted standards of dental practiceDental services a Dentist, exercising prudent clinical judgment, provides that are accepted, effective for the condition, not primarily for convenience or cosmetic, and not more costly than alternatives.

Revision History

12/02/2020initial

Initial release: Revision History indicates initial version dated 12/02/2020 (Initial).

12/06/2020annual_review

Annual review: Revision History lists 12/06/2020 as an annual review.

10/30/2021annual_reviewLatest