CurrentColorado Rocky Mountain Health PlansPolicy CS195.J

Tmj Disorders Cs

Defines medically necessary non-surgical and certain surgical treatments for TMJ disorders, lists procedures considered unproven/not medically necessary, cites InterQual criteria for surgical procedures, and provides related policies, supporting evidence, and applicable billing codes. Excludes state-specific applicability noted in several states.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTmj Disorders Cs

Policy CodePolicy CS195.J

Change TypeRevised/Removed codes and updated references

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument that conservative, reversible, evidence-based treatments were attempted/considered prior to invasive or device-based interventions, consistent with AADOCR and AAOMS recommendations.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary services; removed 'craniosacral manipulation/therapy'.

Removed CPT codes 21089 and 21499 from Applicable Codes.

Updated Description of Services, Clinical Evidence, and References sections to reflect current information.

5Non-surgical services listed as medically necessary

4Surgical services referenced as medically necessary in certain circumstances

4Services listed as unproven/not medically necessary

Device categories labeled unproven

Coverage Summary

This policy (Policy Number CS195.J, effective 2026-06-01) defines coverage for the evaluation and treatment of temporomandibular joint (TMJ) disorders. It identifies non-surgical and certain surgical services considered medically necessary, and lists services and devices that are considered unproven and not medically necessary due to insufficient evidence.

The policy stance is mixed: conservative, reversible, evidence-based non-surgical treatments (e.g., occlusal splints, physical therapy, arthrocentesis, trigger point injections) are endorsed as proven and medically necessary in many circumstances, while specified devices and multiple-splint strategies (e.g., jaw mobility mechanical stretching devices, epigenetic appliances, multiple occlusal splints) and other interventions (e.g., biofeedback in isolation) are described as unproven or of insufficient quality evidence. Refer to InterQual criteria for medical necessity of certain TMJ surgical procedures.

High-level scope metrics

Non-surgical count5

Surgical referenced count4

Unproven services count4

Device categories unproven count2

CPT codes removed count2

Medical-Necessity Criteria

Medically Necessary Non‑Surgical Services

The following non-surgical services are proven and medically necessary for treating disorders of the TMJ:

Arthrocentesis
lavage to remove inflammatory mediators or adhesions
Intra-articular corticosteroid injections: Intra-articular injections of corticosteroids
Trigger point injections
Physical therapy

Coding

Applicable CPT / HCPCS (referenced for services)mixed

20552	Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553	Injection(s); single or multiple trigger point(s), 3 or more muscles
20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound guidance
20606	Arthrocentesis... with ultrasound guidance, with permanent recording and reporting
21010	Arthrotomy, temporomandibular joint
21050	Condylectomy, temporomandibular joint (separate procedure)
21060	Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
21070	Coronoidectomy (separate procedure)
21085	Impression and custom preparation; oral surgical splint
21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

1–10 of 25

1/3

Removed/Deleted CPT codes from Applicable Codes listCPT

21089	removed from Applicable Codes
21499	removed from Applicable Codes

Provider Actions

Documentation Required

Medical Records Documentation

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; presence of documentation does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews.

Prior Authorization

Surgical Services Prior Authorization / Criteria Reference

For TMJ surgical services (arthroscopy, discectomy, reconstruction, arthroplasty), obtain/confirm authorization based on InterQual CP: Procedures or Client Defined CP clinical criteria referenced in the policy.

InterQual CP: Procedures
Client Defined CP: Procedures (Arthroplasty, TMJ) - UHG

Background

Temporomandibular disorders (TMDs) comprise a heterogeneous set of conditions affecting the TMJ and surrounding musculature, with common symptoms including pain at rest and/or during jaw function, limited range of motion, and TMJ noises such as clicking, popping, and crepitus. Many conditions may spontaneously resolve or respond to conservative measures including NSAIDs, soft diet, jaw rest, moist heat, steroids, physical therapy, splints, muscle relaxants, and/or antidepressants.

Clinical guidance from professional organizations (AADOCR, AAOMS) recommends initiating care with the most conservative, reversible, evidence-based therapies and reserving invasive or irreversible procedures for cases that fail conservative management or meet specified criteria.

Procedural descriptions in the policy: Arthrocentesis (lavage) is a minimally invasive irrigation of the joint to remove inflammatory mediators or adhesions and improve mobility. Occlusal splints (stabilization or mandibular repositioning appliances) are intended to reduce clenching/bruxism and reposition the jaw. Myofascial trigger point management includes dry needling or injections (local anesthetic, corticosteroid, dextrose, or saline) to relax muscle fibers and break the pain–tension cycle. Jaw mobility devices (e.g., TheraBite, Jaw Dynasplint, OraStretch, Therapacer) provide passive prolonged stretching for mandibular hypomobility. Epigenetic appliances are intraoral devices similar to retainers that purportedly apply pressure overnight to stimulate bone remodeling; the policy notes a lack of quality evidence supporting their efficacy.

The policy explicitly lists arthrocentesis, intra-articular corticosteroid injections, trigger point injections, physical therapy, and occlusal splints as medically necessary non-surgical services, while identifying biofeedback, jaw mobility mechanical stretching devices, multiple occlusal splints, and epigenetic appliances as unproven and not medically necessary.

Clinical Evidence

The overall quality of evidence across interventions is variable: randomized trials and systematic reviews support short-term benefits for stabilization splints, physical therapy, arthrocentesis (and arthrocentesis combined with injectables), and trigger point injections, but many studies are limited by small sample sizes, heterogeneity, short follow-up, and low-to-moderate quality ratings.

For several device-based or multi-device approaches (jaw mobility mechanical stretching devices, epigenetic appliances, and multiple occlusal splints) and for standalone biofeedback, the evidence is limited, inconsistent, or of low quality; these are therefore classified as unproven and not medically necessary in this policy.

Evidence summary

Arthrocentesis RCTs / systematic reviewsMixed evidence showing improvement in pain and/or mouth opening; some trials show faster pain relief vs splints; limited by small studies and heterogeneity

Corticosteroid injection evidenceSystematic reviews show improvements in pain and MMO when combined with arthrocentesis; evidence quality variable (very low to low)

Physical therapy evidenceRCTs and reviews show benefit when added to splint therapy and as an alternative to splinting; quality variable

Revision History

2026-06-01revisedLatest

Revised list of unproven and not medically necessary services; removed 'craniosacral manipulation/therapy'.

2026-06-01removedLatest

Removed CPT codes 21089 and 21499 from Applicable Codes.

2026-06-01revised

Updated Description of Services, Clinical Evidence, and References sections; previous policy version CS195.I archived.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTmj Disorders Cs

Policy CodePolicy CS195.J

Change TypeRevised/Removed codes and updated references

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

Occlusal splint (stabilization and repositioning splints)

Medically Necessary Surgical Services (Certain Circumstances)

The following TMJ surgical services are proven and medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to InterQual and Client Defined criteria:

Arthroscopy, TMJ: Arthroscopy, Temporomandibular Joint (TMJ) — see InterQual criteria
Refer to InterQual CP: Procedures
Discectomy, TMJ: Discectomy, Temporomandibular Joint (TMJ) — see InterQual criteria
Refer to InterQual CP: Procedures
Reconstruction, TMJ: Reconstruction, Temporomandibular Joint (TMJ) — see InterQual criteria
Refer to InterQual CP: Procedures
Arthroplasty, TMJ: Arthroplasty, Temporomandibular Joint (TMJ) — Client Defined (Custom) - UHG
Refer to InterQual Client Defined CP: Procedures (Arthroplasty)

Services Considered Unproven and Not Medically Necessary

The following services are unproven and not medically necessary due to insufficient evidence of efficacy:

Biofeedback
Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System)
Multiple occlusal splints (e.g., daytime and nighttime splints, maxillary and mandibular splints)
Epigenetic appliances (e.g., Homeoblock, DNA (Daytime/Nighttime appliance), Advanced Lightwire Functional appliance)

Coverage/Medical Necessity Categories in this policy part

Policy distinguishes conservative, reversible, evidence-based initial treatments from devices/therapies identified as unproven or insufficiently evidenced; biofeedback is discussed separately with variable evidence quality.

Conservative-first statement: Conservative, reversible, evidence-based therapeutic modalities (e.g., occlusal splints, physical therapy, biofeedback-based CBT) are recommended as initial treatment per AADOCR and AAOMS guidance.
Policy narrative endorses starting with least invasive therapies.
Devices/therapies identified as unproven or insufficient evidence
- Jaw mobility devices - unproven: Jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint) — considered unproven due to limited, low-quality evidence, small studies, short follow-up, poor adherence, and inconclusive or unfavorable findings.
- Epigenetic appliances - no quality evidence: Epigenetic appliances for TMJ disorders — no quality evidence to support efficacy; effect on health outcomes cannot be established.
Biofeedback note: Biofeedback (including biofeedback-based CBT) — evidence shows reduction in masticatory muscle activity and improvements in pain and coping in some RCTs; evidence quality variable and further RCTs needed.
Biofeedback is described as potentially useful but evidence quality is generally low to moderate.

Billing Rule

Code Reference Usage

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service, nor guarantee reimbursement; other policies/contractual requirements may apply.

Listed CPT/HCPCS codes are provided for reference only

Documentation Required

Use conservative reversible therapies first

Document that conservative, reversible, evidence-based treatments were attempted or considered prior to invasive or device-based interventions, consistent with AADOCR and AAOMS recommendations.

Document attempts of reversible therapies (e.g., occlusal splints, physical therapy, conservative modalities) prior to invasive or device interventions

Prior Authorization

Prior authorization implication for unproven devices

Jaw mobility mechanical stretching devices and epigenetic appliances are described as unproven due to insufficient quality evidence; claims for these devices may be subject to denial or require evidentiary justification per payer policy.

Claims for jaw mobility devices and epigenetic appliances may be subject to denial or require evidence

Billing Rule

CPT code removals

Do not bill CPT codes 21089 and 21499 for services covered under this policy as they were removed from the applicable codes list effective in the 06/01/2026 revision.

21089
21499
Effective date: 2026-06-01 — Do not bill these codes for services covered under this policy

ArthrocentesisMinimally invasive lavage of the TMJ joint space to remove inflammatory mediators or adhesions

Occlusal splintStabilization or mandibular repositioning appliance used to reduce clenching/bruxism and reposition the jaw

Myofascial trigger pointFocal knot in a band of skeletal muscle causing pain; treated with dry needling or injection

BFB-CBTBiofeedback-based cognitive behavioral treatment (biofeedback training plus CBT techniques).

TheraBiteA jaw motion rehabilitation mechanical stretching device used to treat trismus and jaw mobility limitations.

Occlusal splint evidenceSystematic reviews/meta-analyses show short-term benefit for stabilization splints; long-term effects equalize with other therapies

Biofeedback evidenceInsufficient/low-quality evidence; effect on health outcomes not established

Biofeedback RCT (Shedden et al. 2013)BFB-CBT and occlusal splint both reduced pain and disability; BFB-CBT showed larger improvements in pain coping; no change in nocturnal masseter activity

TheraBite vs wooden spatulas (Lee et al. 2018)No significant difference in mean mouth opening at 6 months; exercises ameliorated trismus but differences not significant

Epigenetic appliancesNo quality evidence identified to support efficacy