CurrentColorado Rocky Mountain Health PlansPolicy CS195.I

Treatment of Temporomandibular Joint Disorders

This Colorado Rocky Mountain Health Plans medical policy CS195.I (effective April 1, 2025) defines coverage positions for non-surgical and surgical treatments for temporomandibular joint disorders, lists proven/medically necessary and unproven/not medically necessary services, references InterQual criteria for certain surgical procedures, and provides applicable procedure and supply codes for reference.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTreatment of Temporomandibular Joint Disorders

Policy CodePolicy CS195.I

Change TypeRevisions to unproven services list; state applicability updates; template update

Effective DateApr 1, 2025

Next Review Date

Key ActionUse medical records to document that the member meets clinical criteria for coverage and obtain prior authorization per InterQual criteria for specified TMJ surgeries.

POLICY UPDATE CHANGES

04/01/2025: Revised list of unproven and not medically necessary services replacing earlier wording with 'jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint)' and updated examples of epigenetic appliances including 'Advanced Lightwire Functional (ALF) appliances'.

06/01/2025: Added language that this Medical Policy does not apply to Idaho, Kansas, and New Mexico; refer to state-specific policy versions.

04/01/2026: Template update removed content/language pertaining to the state of Louisiana and updated references.

5Non-surgical services listed as proven/medically necessary

4Surgical services referenced to InterQual as potentially necessary

Services listed as unproven/not medically necessary

3Device/appliance categories discussed (TheraBite/Jaw Dynasplint/epigenetic)

2FDA device classes referenced

Coverage Summary

This policy (Policy Number CS195.I, effective April 1, 2025) defines coverage positions for treatment of temporomandibular joint disorders (TMD/TMJ). It identifies proven, medically necessary non-surgical services — including arthrocentesis, intra-articular corticosteroid injections, trigger point injections, physical therapy, and occlusal splints — and notes certain TMJ surgical procedures (e.g., arthroscopy, discectomy, reconstruction, arthroplasty) are covered when medical necessity criteria are met per InterQual® or InterQual® Client Defined criteria. The policy also lists services considered not medically necessary due to insufficient evidence, such as biofeedback, craniosacral therapy, jaw mobility mechanical stretching devices (e.g., TheraBite®, Jaw Dynasplint®), multiple occlusal splints, and epigenetic appliances (e.g., Homeoblock™, DNA®, ALF).

High-level Key Facts

Non-surgical proven count5

Surgical referenced to InterQual count4

Unproven/not medically necessary count5

FDA device classes referencedClass II (CPM machines), Class III (TMJ prostheses)

Examples of device/appliance categories discussedTheraBite, Jaw Dynasplint, Epigenetic appliances (e.g., ALF)

Professional societies citedAADOCR, AAOMS

Medical-Necessity Criteria

Proven and Medically Necessary Non-Surgical Services

Covered when clinically indicated per policy and supporting clinical criteria:

Arthrocentesis
Intra-articular corticosteroids: Intra-articular injections of corticosteroids
Trigger point injections
Physical therapy
Occlusal splint (stabilization and repositioning splints)

Clinical Guidance & FDA Information

Clinical Guidance / Conservative Therapy

Professional society guidance and general coverage principles:

AADOCR guidance: AADOCR recommends initial treatment of TMD patients should be conservative, reversible, and evidence-based; many conservative modalities provide symptomatic relief and carry less risk than invasive treatments.
AAOMS surgical guidance: AAOMS: Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain/dysfunction are moderate to severe; surgery not indicated for asymptomatic or minimally symptomatic patients or for preventive reasons.
AAOMS orthognathic criteria: AAOMS Recommended Criteria for Orthognathic Surgery: non-surgical therapies should be attempted prior to orthognathic procedures when TMJ dysfunction is present; literature reports approximately 80% improvement after orthognathic surgery in some patients.

Provider Actions & Prior Authorization

Prior Authorization

Refer to InterQual for certain TMJ surgeries

Coverage for certain temporomandibular joint (TMJ) surgical procedures is subject to InterQual medical necessity criteria and prior authorization per plan requirements. Providers should refer to InterQual criteria (InterQual CP or InterQual Client Defined CP) and obtain prior authorization when requesting coverage for the listed procedures. Documentation and meeting InterQual-defined clinical criteria are required to determine medical necessity and coverage.

29800
29804
21010
21240
21243

Documentation Required

Use medical records to support medical necessity

Coding (Reference)

Referenced CPT/HCPCS/Other Codes (for reference only; inclusion does not imply coverage)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, aspiration and/or injection, intermediate joint or bursa; 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
21089	Unlisted maxillofacial prosthetic procedure

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Background and Evidence Summary

Temporomandibular disorders (TMD) are a diverse set of conditions affecting the TMJ and surrounding musculature, presenting with jaw pain, limited range of motion, and joint noises. Experts recommend a conservative-first, reversible approach: initial management commonly includes NSAIDs, soft diet, jaw rest, moist heat, physical therapy, splints, muscle relaxants, and behavioral interventions. If conservative care fails, escalation may include injection therapies or surgery. This policy summarizes the scope of treatments considered (conservative, minimally invasive, and surgical), evidence supporting them, and services judged unproven or not medically necessary.

Key Evidence Summaries

Arthrocentesis - evidenceMultiple RCTs and systematic reviews show arthrocentesis can reduce pain and often improve mouth opening versus conservative measures, with some studies showing faster pain relief or added benefit when combined with HA or PRP; overall quality and heterogeneity vary.

Corticosteroid injections - evidenceSystematic reviews (very low to low quality) suggest intra-articular corticosteroids can reduce pain short- to intermediate-term, often showing benefit when used with arthrocentesis; evidence limited by heterogeneity.

Trigger point injections - evidenceNetwork meta-analysis of RCTs (low/very low quality) indicates needling therapies (dry/wet needling, local anesthetic, PRP, BTX‑A) may improve pain and MMO versus placebo, but evidence quality is low.

Definitions

Arthrocentesis: TMJ lavage/aspiration and/or injection of the joint (intermediate joint/bursa) with or without guidance, used to reduce pain and improve mouth opening.

Occlusal splint: Stabilization (night guard) or mandibular repositioning splint/device intended to reduce clenching/bruxism and to reposition or relax the jaw.

Jaw mobility mechanical stretching devices: devices such as TheraBite Jaw Motion Rehabilitation System® and Jaw Dynasplint® used to provide passive or prolonged-duration stretching to treat or prevent trismus/mandibular hypomobility.

Epigenetic appliances: Intraoral orthodontic-like appliances (examples include Advanced Lightwire Functional (ALF) appliances) proposed for TMD treatment but for which quality evidence of efficacy is lacking.

Revision History

04/01/2025revised

Revised list of unproven and not medically necessary services replacing earlier wording with 'jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint)' and updated examples of epigenetic appliances including 'Advanced Lightwire Functional (ALF) appliances'. Also updated Medical Records Documentation Used for Reviews language and Supporting Information sections; archived previous policy CS195.H.

06/01/2025revised

Added language that this Medical Policy does not apply to Idaho, Kansas, and New Mexico; refer to state-specific policy versions.

04/01/2026revisedLatest

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTreatment of Temporomandibular Joint Disorders

Policy CodePolicy CS195.I

Change TypeRevisions to unproven services list; state applicability updates; template update

Effective DateApr 1, 2025

Next Review Date

Key ActionUse medical records to document that the member meets clinical criteria for coverage and obtain prior authorization per InterQual criteria for specified TMJ surgeries.

On This Page

Proven and Medically Necessary Surgical Services (certain circumstances)

Covered when medical necessity clinical coverage criteria are met (refer to InterQual CP/Client Defined CP where indicated):

Arthroscopy, TMJ: Arthroscopy, Temporomandibular Joint (TMJ) — per InterQual® CP: Procedures
Refer to InterQual® CP: Procedures
Discectomy, TMJ: Discectomy, Temporomandibular Joint (TMJ) — per InterQual® CP: Procedures
Refer to InterQual® CP: Procedures
Reconstruction, TMJ: Reconstruction, Temporomandibular Joint (TMJ) — per InterQual® CP: Procedures
Refer to InterQual® CP: Procedures
Arthroplasty, TMJ (custom/UHG): Arthroplasty, Temporomandibular Joint (TMJ) (custom/UHG) — per InterQual® Client Defined CP
Refer to InterQual® Client Defined CP: Procedures

Services Considered Unproven and Not Medically Necessary

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

Biofeedback
Craniosacral therapy: Craniosacral manipulation/therapy
Jaw mobility devices: Jaw mobility mechanical stretching devices (e.g., TheraBite®, Jaw Dynasplint® System)
Multiple occlusal splints (i.e., daytime and nighttime splints, maxillary and mandibular splints)
Epigenetic appliances (e.g., Homeoblock™, DNA®, Advanced Lightwire Functional (ALF) appliances)

Coverage Rationale - Unproven / Not Medically Necessary Services

Services listed below are considered unproven or not medically necessary due to insufficient quality evidence of efficacy and safety:

Jaw mobility devices rationale: Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System) are considered unproven due to limited studies, small sample sizes, short follow-up, low compliance, and inconclusive or unfavorable results.
Epigenetic appliances rationale: Epigenetic appliances are considered unproven; literature does not identify quality evidence to support efficacy for TMD.
Craniosacral therapy rationale: Craniosacral manipulation/craniosacral therapy evidence is limited; clinical trial findings are inconclusive regarding efficacy for TMD.
Informational; effect on health outcomes cannot be established.

FDA Information (Informational Only)

Regulatory status relevant to devices (informational only; FDA approval is not a basis for coverage):

TMJ prostheses are regulated as Class III devices requiring PMA; product codes LZD and MPI (FDA PMA database).
Informational only; FDA approval is not coverage
CPM machines: Continuous passive motion (CPM) machines are FDA Class II devices (product code BXB).
Informational only
FDA safety communication March 2023: March 2023 FDA safety communication regarding jaw remodeling devices for adults (safety concern).
Informational only; see FDA website for details

Medical records documentation may be required to demonstrate that a member meets the clinical criteria for coverage. Submission of documentation supports the medical necessity review but does not guarantee that the service will be covered. Benefit coverage is determined by applicable federal, state, or contractual requirements and applicable laws.

Coverage determination is governed by federal, state, or contractual requirements.

Documentation Required

Medical records documentation for review

Medical records documentation may be requested to assess whether the member meets the clinical criteria for coverage. Providing records facilitates review but does not ensure approval; benefit coverage is ultimately determined by federal, state, or contractual requirements and applicable laws.

Documentation required for review is governed by federal, state, or contractual rules.

Physical therapy - evidenceRCTs and systematic reviews show manual therapy, exercise, and multimodal PT (often equivalent or additive to splints) improve pain and ROM; quality ranges low to moderate and benefits may be maintained when combined with exercise.

Occlusal splints - evidenceNetwork meta-analyses and systematic reviews report moderate to very low quality evidence supporting occlusal splints for TMD; multimodal therapy (counseling + hard stabilization splint) may yield maximal improvement.

Biofeedback/craniosacral/jaw devices - evidenceInsufficient or low-quality evidence; craniosacral and biofeedback studies are low quality and jaw mobility devices show small studies, poor compliance, and inconclusive or unfavorable results (considered unproven/not medically necessary).

Notable RCTsKey trials include Corrêa‑Silva 2024 (arthrocentesis vs splint), Yilmaz 2019 (arthrocentesis+HA vs HA), Kraaijenga 2014 and Lee 2018 (TheraBite vs PT/wooden spatulas), and Romeo 2024 (PT + splint RCT showing additive benefit).

Template update removed content/language pertaining to the state of Louisiana and updated references.