CurrentEmpire BluecrossPolicy 09-400

Occlusal Guard Guidelines

Defines clinical indications, exclusions, documentation requirements, and applicable CDT procedure codes for occlusal guards used to protect teeth from bruxism/clenching and to relieve occlusal stress following periodontal therapy. States that occlusal guards are not appropriate treatment for temporomandibular disorders and outlines contract-dependence of coverage.

Policy Summary

PayerEmpire Bluecross

PolicyOcclusal Guard Guidelines

Policy CodePolicy 09-400

Change TypeRevised (Annual Review)

Effective DateJan 1, 2024

Next Review Date

Key ActionProviders must supply a narrative with rationale for treatment when requesting occlusal guard services.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised; last review date 11/01/2023 and publish date 01/01/2024 are documented.

5Key Clinical Indications/Points Listed

5CDT Codes Provided

Coverage Summary

Policy 09-400: Occlusal Guard (removable dental appliance). Status: CURRENT (Revised). Effective date: 01/01/2024; Last review: 11/01/2023. This policy defines clinical indications, exclusions, documentation requirements, and applicable CDT procedure codes for occlusal guards used to protect teeth from bruxism/clenching and to relieve occlusal stress following periodontal therapy. Coverage is contract dependent and excludes certain uses (see exclusions).

Medical Necessity Criteria

Medically Appropriate Use (Covered when ALL of the following are met)

Occlusal guards may be considered appropriate when used to protect natural teeth or relieve occlusal stress and when documentation is provided:

ALL of the following

Occlusal guards are used to protect natural teeth when the opposing dentition has the potential to cause enamel wear or damage such as the presence of porcelain or ceramic restorations
Occlusal guards are used to minimize tooth sensitivity caused by clenching or bruxism
Occlusal guards may be necessary and appropriate to relieve stress from occlusion following periodontal therapy
A narrative with rationale for treatment is provided
Documentation requirement explicitly stated
Arch coverage
- Full-arch occlusal guards (e.g., hard appliance full arch, soft appliance full arch)
- Partial arch occlusal guards
  Partial arch occlusal guards may not be a covered service, contract dependent

Operational note: When any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also not covered or denied.

Not Indicated / Exclusions

Occlusal guards are not indicated for the following uses:

ANY of the following

Use as an athletic mouth guard
Treatment of temporomandibular disorders or myofascial pain dysfunction
By definition, not an appropriate treatment or therapy for TMD
Use as an appliance intended for orthodontic tooth movement
Tooth whitening, fluoride delivery, or the delivery of periodontal medicaments
Treatment of obstructive sleep apnea

Coding (CDT / ICD-10)

CDT codes (informational list)mixed

D0320	temporomandibular joint arthrogram, including injection
D0321	other temporomandibular joint radiographic images, by report
D0330	panoramic radiographic images
D0470	diagnostic casts
D7880	occlusal orthotic device
D7881	occlusal orthotic device adjustment
D9130	temporomandibular joint dysfunction - non-invasive physical therapies
D9941	fabrication of athletic mouth guard
D9942	repair and/or reline of occlusal guard
D9943	occlusal guard adjustment

1–10 of 13

1/2

ICD-10-CM DiagnosesICD-10

Refer to current CDT code book for details; ICD-10-CM diagnoses for dental diseases and conditions (see current CDT code book and ICD-10-CM guidance)

Provider Actions & Billing Guidance

Documentation Required

Narrative Rationale Required

Providers must supply a narrative with rationale for treatment when requesting occlusal guard services.

Denial Risk

Related Services Denied if Primary Service Not Covered

When an occlusal guard service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also not covered or denied.

Billing Rule

Verify Member Contract Benefits

Inclusion of procedure codes in the policy is informational only; providers must refer to the member's contract benefits at time of service to determine coverage or non-coverage.

Background, Evidence & Definitions

Occlusal guards are removable appliances constructed of rigid or semi-rigid material to minimize or eliminate the effects of bruxism or clenching that can cause excessive wear or fractures of natural teeth or restorations. They are used to protect teeth (including when opposing dentition could cause enamel wear or damage), to minimize tooth sensitivity from clenching/bruxism, and to relieve occlusal stress following periodontal therapy when justified by documentation. By definition, occlusal guards are not an appropriate treatment or therapy for temporomandibular disorders (TMD), and use for TMD or myofascial pain dysfunction is specifically excluded.

References cited:

Term	Definition
Dental review as it applies to accepted standards of care
Dental services that a dentist, exercising prudent clinical judgment, provides to evaluate, diagnose or treat a dental injury or disease and that are in accordance with generally accepted standards of dental practice, effective for the patient's condition, and not primarily for provider convenience.
Generally accepted standards of dental practice
Standards based on credible scientific evidence in peer-reviewed dental literature, specialty society recommendations, views of recognized dentists, and other credible sources.

Revision History

11/01/2023annual_reviewLatest

Annual Review conducted on 11/01/2023; Revision history documents multiple annual reviews with the latest entry on 11/01/2023.

01/01/2024publishLatest

Policy publish date 01/01/2024; policy status marked Revised.

10/30/2021annual_review

Annual Review conducted on 10/30/2021 as listed in the revision history.

11/11/2022annual_review

Annual Review conducted on 11/11/2022 as listed in the revision history.

10/07/2020annual_review

Annual Review conducted on 10/07/2020 as listed in the revision history.

12/06/2020revision

Revision recorded on 12/06/2020 in the revision history.

06/20/2018initial

Initial policy entry dated 06/20/2018 as listed in the revision history.