Treatment of Temporomandibular Joint Disorders (for Kansas Only)

Coverage Summary

UnitedHealthcare Medical Policy CS195KS.02 (Kansas only), effective June 1, 2026, defines coverage and medical necessity for nonsurgical and surgical treatments of temporomandibular joint disorders for members both 18 years and older and under 18 years. The policy lists specific nonsurgical services considered proven and medically necessary (including arthrocentesis, intra-articular corticosteroid injections, trigger point injections, physical therapy, and occlusal splints), describes surgical services as conditionally covered with medical necessity determined by InterQual criteria, and identifies a revised list of services and devices considered unproven / not medically necessary. The overall coverage stance in the policy reflects a mixed approach: certain nonsurgical services are covered as proven, surgical procedures are covered conditionally per external InterQual criteria, and several interventions/devices are designated not medically necessary due to insufficient evidence.

Policy headline and guideline counts

Nonsurgical Services Listed as Medically Necessary (Adults)5

Surgical Services Listed as Medically Necessary (conditional)4

Unproven/Not Medically Necessary Examples (adult)3

Unproven/Not Medically Necessary Examples (pediatric)4

Guideline bodies cited2

Members 18 Years of Age and Older — Nonsurgical Medical-Necessity Criteria

Members 18 Years of Age and Older - Proven and Medically Necessary Nonsurgical Services

Covered when ALL of the following are met:

ALL of the following

Arthrocentesis: Indicated to remove inflammatory mediators or to lyse intra‑articular adhesions when conservative therapy (e.g., medications, soft diet, jaw rest, moist heat, splint therapy, or physical therapy) has failed to improve symptoms or range of motion.
Intra‑articular injections of corticosteroids: Indicated for persistent TMJ joint inflammation or effusion when conservative measures have not produced adequate symptom relief and when injection is performed by an appropriate specialist with documentation of indication and technique.
Trigger point injections: Indicated for focal myofascial trigger points contributing to TMJ pain when conservative measures (e.g., physical therapy, home exercise, medications) have been insufficient; may be performed as dry needling or with injection (e.g., corticosteroid, dextrose, saline) as clinically appropriate.

Members 18 Years of Age and Older — Surgical Medical-Necessity Criteria (Conditional)

Members 18 Years of Age and Older - Proven and Medically Necessary Surgical Services (conditional; see InterQual criteria)

Covered when the InterQual CP: Procedures medical necessity criteria are met:

ANY of the following

Arthroplasty, Temporomandibular Joint (TMJ)
Arthroscopy, Temporomandibular Joint (TMJ)
Discectomy, Temporomandibular Joint (TMJ)
Reconstruction, Temporomandibular Joint (TMJ)

Members 18 Years of Age and Older — Unproven and Not Medically Necessary Services

Members 18 Years of Age and Older - Unproven and Not Medically Necessary Services

Not covered due to insufficient evidence of efficacy (list not all inclusive):

ANY of the following

Biofeedback
Insufficient quality evidence to establish effect on health outcomes.
Multiple occlusal splints (e.g., daytime and nighttime splints, maxillary and mandibular splints)
No published evidence supports use of more than one splint concurrently.
Epigenetic appliances (e.g., Homeoblock™, DNA® Daytime/Nighttime appliance, Advanced Lightwire Functional appliances)
No quality evidence supporting efficacy for TMJ disorders.

The policy includes an updated "Unproven / Not Medically Necessary Services (revised list)" section that identifies services considered unproven or not medically necessary due to insufficient evidence of efficacy (for example, biofeedback, multiple occlusal splints, epigenetic appliances, jaw mobility mechanical stretching devices in the pediatric list). These items were revised in the June 1, 2026 update and are presented as services that the policy considers unproven/not medically necessary rather than as covered interventions.

Members Under 18 Years of Age — Nonsurgical Medical-Necessity Criteria

Members Under 18 Years of Age - Proven and Medically Necessary Nonsurgical Services

Covered when clinically indicated:

ALL of the following

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

Members Under 18 Years of Age — Surgical Medical-Necessity Criteria (Conditional; InterQual Client Defined)

Members Under 18 Years of Age - Proven and Medically Necessary Surgical Services (conditional; see InterQual Client Defined CP)

Covered when the UnitedHealth Group InterQual Client Defined CP: Procedures criteria are met:

ANY of the following

Arthroplasty, Temporomandibular Joint (TMJ) (per InterQual custom criteria)

For members under 18 years, the policy now references external clinical criteria changes: certain InterQual modules were removed and an InterQual® Client Defined CP: Procedures — Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UnitedHealth Group was added. The revision notes removal of references to several InterQual CP modules and the addition of the InterQual Client Defined criteria for pediatric TMJ arthroplasty to guide conditional surgical coverage.

Documentation Requirements

Documentation Requirement

ALL of the following

The patient’s medical record must contain documentation that fully supports the medical necessity for the requested services.
Documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient’s medical record, and made available upon request.

Documentation Required

Medical record documentation must support medical necessity

Medical record documentation must support medical necessity. Records should include relevant history, examination findings, and results of diagnostic tests or procedures that justify the requested service. Documentation must be legible, retained in the patients medical record, and made available to UnitedHealthcare upon request.

Prior Authorization & Use of External Criteria

Prior Authorization

Surgical TMJ procedures require InterQual criteria

Coverage for TMJ arthroplasty, arthroscopy, discectomy, and reconstruction is conditional. Medical necessity clinical coverage criteria must be met per the InterQual CP: Procedures (for adults) or the InterQual Client Defined, CP: Procedures, Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UnitedHealth Group (for pediatric members). Providers should reference InterQual when requesting preauthorization or determining medical necessity for these surgical TMJ procedures.

Note

Use of InterQual and other criteria for coverage decisions

UnitedHealthcare uses InterQual for primary medical/surgical criteria (and ASAM for SUD). If InterQual does not have applicable criteria, UnitedHealthcare may use UnitedHealthcare Medical Policies that have been approved by the Kansas Department of Health and Environment. Before making coverage determinations, check federal, state, or contractual requirements that may affect coverage.

Coding

Trigger Point Injection CPTCPTCovered

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

Arthrocentesis and Related CPTCPTCovered

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

TMJ Surgical CPT Codes (refer to InterQual for medical necessity)CPTCovered

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
21240	Arthroplasty, TMJ, with or without autograft (includes obtaining graft)
21242	Arthroplasty, TMJ, with allograft
21243	Arthroplasty, TMJ, with prosthetic joint replacement
21247	Reconstruction of mandibular condyle with bone and cartilage autografts

1–10 of 13

1/2

Biofeedback and Related Codes (Not Medically Necessary)mixedNot Covered

90901	Biofeedback training by any modality
97039	Unlisted modality (specify type and time if constant attendance)
97139	Unlisted therapeutic procedure (specify)
E0746	Electromyography (EMG), biofeedback device

Jaw Mobility Devices and DME (Not Medically Necessary for under-18 list; jaw mobility devices listed as unproven)HCPCSNot Covered

E1399	Durable medical equipment, miscellaneous
E1700	Jaw motion rehabilitation system
E1701	Replacement cushions for jaw motion rehabilitation system, package of 6
E1702	Replacement measuring scales for jaw motion rehabilitation system, package of 200

Applicable Codes (policy references Applicable Codes section updated)mixed

No codes listed

Background, Evidence, and Definitions

Temporomandibular disorders (TMD) are a diverse set of conditions affecting the TMJ and surrounding musculature, commonly causing pain, limited range of motion, and joint noises. Guideline and policy guidance emphasize a conservative-first, reversible approach because many TMDs improve over time; more invasive options are reserved for patients who fail conservative care. Arthrocentesis is described as a minimally invasive joint lavage in which irrigants are injected into the joint space to remove inflammatory mediators or adhesions and improve mobility. Occlusal splints (stabilization or mandibular repositioning devices) aim to reduce clenching/bruxism and reposition the jaw to a more relaxed state. Trigger point injections target myofascial trigger points to relax muscle fibers and reduce pain and may be performed as dry needling alone or followed by injectate.

Study / Source	Key Finding
Corrêa-Silva et al., 2024 RCT
Arthrocentesis produced faster pain relief at 1 month versus occlusal splint; similar outcomes between groups at 6 months with splint showing greater increase in mouth opening at 6 months
Li et al., 2022 (systematic review, network meta-analysis)
Most invasive treatments outperformed noninvasive; arthrocentesis plus platelet-rich plasma and platelet-rich plasma alone ranked highest for mouth opening and pain in disc displacement (limited by indirectness of network analysis)
Leung et al., 2020 (systematic review)
No significant differences between ultrasonography-guided and conventional arthrocentesis; both effective for pain reduction and improving maximum mouth opening
Multiple systematic reviews/meta-analyses (2017-2025)
Evidence is mixed-quality supporting arthrocentesis, arthroplasty, corticosteroid injections, trigger point injections, physical therapy, and occlusal splints; biofeedback and several devices have low/insufficient evidence
Biofeedback RCT (Shedden et al., 2013)
BFB-CBT and occlusal splint both reduced pain intensity and disability with similar clinically meaningful improvement; BFB-CBT improved pain coping and satisfaction; no significant changes in nocturnal masseter muscle activity
TheraBite vs wooden spatula (Lee et al., 2018)
No significant difference in mouth opening or quality of life; exercises improved trismus but TheraBite was not superior
Jaw Dynasplint feasibility (Zatarain et al., 2018)
Low adherence (25% used as prescribed) and decreased adherence versus conventional stretching; more trismus diagnoses in Dynasplint arm; unlikely to be efficacious due to low adherence
TheraBite vs physical therapy (Kraaijenga et al., 2014)
Both TheraBite and standard physical therapy were equally effective at 3 months; TheraBite showed greater functional improvement at 1 week

Arthrocentesis: Minimally invasive irrigation of the joint to remove inflammatory mediators or adhesions.

Occlusal splint: Stabilization or mandibular repositioning device intended to reduce clenching/bruxism and reposition the jaw.

Trigger point injection: Injection into myofascial trigger points to relax muscle fibers and reduce pain; may be dry needling or followed by injectate.

Unproven / Not medically necessary: Services or devices lacking sufficient quality evidence demonstrating efficacy and safety for TMJ/TMD; coverage is not supported.

Unproven / Not Medically Necessary — Rationale

Unproven / Not Medically Necessary Services (revised list)

The following services/devices are considered unproven or not medically necessary based on insufficient/low-quality evidence:

ALL of the following

Epigenetic appliances — insufficient quality evidence to support efficacy for TMJ disorders
Jaw mobility mechanical stretching devices — considered unproven due to insufficient quality evidence of efficacy and safety; limited adherence and inconclusive or unfavorable findings
Examples include TheraBite and Jaw Dynasplint systems.
Biofeedback: evidence is low-quality overall though some studies show reduction in muscle activity; not established as proven
Existing studies are small, heterogeneous, and of low quality; benefit as isolated therapy is not established.

Clinical Recommendation Context

Guideline-based conservative-first approach:

AADOCR: initial treatment of TMD should be conservative, reversible, and evidence-based; many TMDs improve over time

AAOMS: thorough history/exam, imaging, correct diagnosis, and initiation of the least invasive surgical or nonsurgical treatment; surgery reserved for patients failing minimally invasive procedures and with moderate to severe pain/dysfunction; not for asymptomatic or minimally symptomatic patients

Revision History

2026-06-01material_revisionLatest

Revised list of unproven and not medically necessary services for Members 18 and older and Members under 18; removed craniosacral manipulation/therapy and removed jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System) from the unproven/not medically necessary list; updated pediatric InterQual references (added InterQual Client Defined CP: Procedures, Arthroplasty, TMJ (Custom) - UHG and removed references to specific InterQual CP modules for arthroplasty, arthroscopy, discectomy, and reconstruction).

2026-06-01non_material_clarification

Updated Supporting Information sections (Description of Services, Clinical Evidence, and References) and archived prior policy version CS195KS.01; added/clarified medical records documentation language regarding documentation requirements and determination of benefit coverage by federal, state, or contractual requirements.