CurrentColorado Rocky Mountain Health PlansPolicy DCP019.13

Occlusal Guards

Defines indications and non-indications for occlusal guards (dental appliances) used to protect dentition from bruxism, clenching, or opposing restorative materials; links to related TMJ policy and lists applicable CDT procedure codes. Applies to interpretation of UnitedHealthcare standard and Medicare Advantage dental plans; member benefit documents govern coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOcclusal Guards

Policy CodePolicy DCP019.13

Change TypeRevised — CDT codes updated; D9936 added

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders should document clinical findings demonstrating bruxism/clenching with resulting excessive wear or fractures, or documentation that opposing dentition (e.g., porcelain/ceramic restorations) may cause enamel wear, to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable CDT codes to reflect annual edits; added D9936.

2Primary Covered Indications

4Not Indicated Uses Listed

6Applicable CDT Codes Provided

Coverage Summary

Medical Necessity / Indications and Exclusions

Medically Indicated / Covered Indications

Occlusal guards are indicated when ANY of the following are present:

Bruxism or clenching (nocturnal parasomnia or during waking hours) resulting in excessive wear or fractures of natural teeth or restorations
To protect natural teeth when the opposing dentition has the potential to cause enamel wear such as the presence of porcelain or ceramic restorations

Not Indicated / Not Covered

Occlusal guards are not indicated for the following (coverage not supported):

As an appliance intended for orthodontic tooth movement
For treatment of temporomandibular disorders
See related Medical Policy on Treatment of Temporomandibular Joint Disorders
For treating headaches or other pain disorders of the craniofacial region
As a mouthguard to protect the dentition during sports

Provider Actions & Billing Guidance

Documentation Required

Document indication of bruxism or opposing restorations

Document clinical findings that demonstrate bruxism or clenching resulting in excessive wear or fractures of natural teeth or restorations, or document that opposing dentition (for example, porcelain or ceramic restorations) may cause enamel wear. These clinical findings support medical necessity for occlusal guard services.

D9944
D9945
D9946

Billing Rule

Use applicable CDT codes for occlusal guard services

Report the appropriate CDT code for fabrication, adjustment, repair, cleaning/inspection, or reline of occlusal guards as listed in the policy. Inclusion of a code in the policy does not guarantee coverage; member-specific benefit documents and applicable laws determine actual benefit and reimbursement.

D9936
D9942
D9943
D9944
D9945
D9946

Background & Definitions

Occlusal guards are rigid, semi-rigid, or soft dental appliances fabricated to cover teeth to protect them from bruxism and clenching. They may be constructed in-office or by an outside laboratory. They are not intended as treatment for temporomandibular disorders.

Definitions

Evidence / Sources