ModifiedUnitedHealthcarePolicy CS195NJ.F

Treatment of Temporomandibular Joint Disorders (for New Jersey Only)

Policy governs medical necessity and coverage of non-surgical and surgical treatments for temporomandibular joint disorders for UnitedHealthcare members in New Jersey.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for New Jersey Only)

Policy CodePolicy CS195NJ.F

Change TypeRevised unproven device/appliance exampleseditorial updates to evidence and references

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionVerify prior authorization requirements and document medical necessity per InterQual and the member's plan before scheduling TMJ surgical procedures.

SourceLink

POLICY UPDATE CHANGES

Replaced prior wording with explicit reference to 'jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint)' and expanded examples of epigenetic appliances to include Advanced Lightwire Functional (ALF) appliances.

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

5Non-surgical services listed as medically necessary

MultipleSurgical procedures aligned to InterQual criteria

>=36Studies in systematic reviews cited

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Policy application state

6 moMinimum follow-up referenced

very low–moderateEvidence quality

Coverage Criteria for TMJ/TMD Treatments

Medically Necessary Non-Surgical Services

Covered when provided for treatment of TMJ disorders per clinical judgment and member benefit:

Required items: Arthrocentesis

Proven and medically necessary non-surgical service per policy.

Required items: Intra-articular injections of corticosteroids

Proven and medically necessary non-surgical service per policy.

Required items: Trigger point injections

Proven and medically necessary non-surgical service per policy.

Required items: Physical therapy

Proven and medically necessary non-surgical service per policy.

Required items: Occlusal splint (stabilization and repositioning splints)

Proven and medically necessary non-surgical service per policy.

Medically Necessary Surgical Services (conditional)

Covered only in certain circumstances and when medical necessity criteria are met per InterQual:

Surgical procedures governed by InterQual: Arthroscopy, Discectomy, Reconstruction, Arthroplasty (TMJ)

Refer to InterQual CP/Client Defined criteria for specific medical necessity requirements and prior authorization before coverage.

Services Considered Unproven / Not Medically Necessary

Not medically necessary due to insufficient evidence of efficacy (not all-inclusive):

Unproven services: Biofeedback

Listed explicitly as unproven and not medically necessary.

Unproven services: Craniosacral manipulation/therapy

Listed explicitly as unproven and not medically necessary.

Unproven services: Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System)

Listed explicitly as unproven and not medically necessary.

Unproven services: Multiple occlusal splints (daytime and nighttime, maxillary and mandibular)

Overall coverage considerations

Coverage stance derived from cited evidence and professional guidance in this section

Conservative first: Initial management should use conservative, reversible, evidence-based therapies (for example, occlusal splints, physical therapy, education) unless specific indications for more invasive treatment exist.

Based on AADOCR recommendation that conservative, reversible therapies be used initially and supported by cited trials.

Minimally invasive options: Minimally invasive procedures (arthrocentesis with or without injectables; intra-articular corticosteroids or hyaluronic acid; arthroscopy; needling therapies such as dry needling, PRP, or local trigger-point injections) may provide short- to intermediate-term improvement in pain and/or maximum mouth opening; evidence quality is heterogeneous (very low to moderate) and follow-up in trials often reported at 6 months or longer.follow-up often reported at 6 months

Multiple systematic reviews and network meta-analyses support benefit but note low-quality evidence and limitations.

Surgery consideration:

Multiple occlusal splints (including daytime and nighttime, maxillary and mandibular appliances) and epigenetic appliances are listed in this policy as unproven and not medically necessary because the literature does not provide sufficient quality evidence of clinical benefit. The policy explicitly names examples of epigenetic appliances, including Homeoblock™, DNA® (Daytime/Nighttime appliance), and Advanced Lightwire Functional (ALF) appliances as unproven for treatment of temporomandibular disorders.

Jaw mobility mechanical stretching devices, epigenetic appliances, and craniosacral manipulation/therapy are considered unproven due to insufficient quality evidence and cannot currently be established as effective treatments for TMD. The literature is limited by small sample sizes, short follow-up, low compliance in device studies, and inconclusive or unfavorable findings, and therefore these modalities are categorized as not medically necessary.

The policy was revised to update the list of services considered unproven/not medically necessary to explicitly include jaw mobility mechanical stretching devices (for example, TheraBite Jaw Motion Rehabilitation System® and Jaw Dynasplint® System) and to expand examples of epigenetic appliances (addition of ALF appliances). This change is reflected in the Summary of Changes dated 04/01/2025.

The policy identifies biofeedback and craniosacral therapy/manipulation as unproven and not medically necessary for TMD. Although related device and HCPCS codes (for example, 90901 for biofeedback training and E0746 / E1700 for biofeedback and jaw motion systems) are listed in the coding section for reference, the presence of codes does not imply coverage when the service itself is designated unproven.

Available systematic reviews and trials for biofeedback and craniosacral manipulation are of low quality or otherwise inadequate to establish clinical benefit. For biofeedback, existing studies are generally small, short duration, and lack standardized protocols; for craniosacral manipulation, the literature did not identify quality evidence supporting efficacy for TMJ conditions. As a result, the policy concludes that the effect of these interventions on meaningful health outcomes cannot be established.

Specific examples of jaw mobility mechanical stretching devices cited in the policy include the TheraBite Jaw Motion Rehabilitation System® and the Jaw Dynasplint® System. Study reports note limited compliance and inconclusive benefits; therefore these devices are included in the revised list of unproven and not medically necessary services.

Coding and Procedural Codes

Applicable CPT/Procedure Codes (surgical and injections)CPT

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.

1–10 of 18

1/2

Additional CPT CodesCPT

29804	Arthroscopy, temporomandibular joint, surgical.
90901	Biofeedback training by any modality.
97039	Unlisted modality (specify type and time if constant attendance).
97139	Unlisted therapeutic procedure (specify).

HCPCS / DME CodesHCPCS

E0746	Electromyography (EMG), biofeedback device.
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.

Follow-up/outcome timepoints referenced in evidence

Common study follow-up intervals1 month, 2 months, 3 months, 6 months and longer (some studies report outcomes up to years)

Short-term reportingOutcomes reported at ≤5 months in network meta-analyses for pain and mouth opening

Intermediate-term reportingOutcomes reported at ≥6 months (often defined as >6 months to 4 years) in systematic reviews

Trial-specific timepointsRandomized trials commonly evaluated at 1, 2, 3, and 6 months (example: Corrêa-Silva et al. evaluated at 1,2,3,6 months)

Provider Actions, Authorization & Documentation

Denial Risk

Coverage contingent on benefits/medical necessity

Coverage is contingent on the enrollee's benefit plan and demonstration of medical necessity. Inclusion of a procedure or code in this policy does not guarantee coverage or payment; benefits are determined by the member's federal, state, or contractual plan terms and applicable laws.

Coverage depends on applicable benefit provisions and medical necessity documentation.
Listing of a code in this policy is for reference and does not imply coverage or payment.

Note

FDA informational note

FDA regulatory status is provided for informational purposes only. FDA approval or classification (e.g., Class II or Class III device status, PMA approvals, or safety communications) is not by itself a basis for coverage.

TMJ prostheses are regulated as Class III devices (PMA).
Continuous passive motion (CPM) machines are Class II devices.

Background and Scope

Temporomandibular disorders (TMD) are a heterogeneous group of conditions affecting the temporomandibular joint and surrounding muscles that can cause jaw pain, limited mouth opening, joint noises (clicking/crepitus), and masticatory muscle dysfunction. Many cases improve with conservative measures — for example, education, activity modification, NSAIDs, occlusal splints, and physical therapy — and invasive options (injections or surgery) are generally reserved for patients who do not respond to conservative management or who have significant joint pathology.

Definitions

Occlusal splint — definition and intended purpose

DefinitionAn oral appliance (stabilization splint or mandibular repositioning splint) intended to reduce clenching/bruxism and to reposition the jaw to relieve TMD symptoms.

TypesStabilization splints (night guards/occlusal guards) and mandibular repositioning devices.

Intended purposeReduce/eliminate tooth clenching/bruxism, maintain or reposition the jaw in a more relaxed position to improve pain and function.

Myofascial trigger point — definition and implication for injections

DefinitionFocal knots in a band of skeletal muscle caused by acute or repeated microtrauma; common in TMJ disorders.

Clinical implicationTrigger points contribute to pain and dysfunction in masticatory muscles and are a target for intervention.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for New Jersey Only)

Policy CodePolicy CS195NJ.F

Change TypeRevised unproven device/appliance exampleseditorial updates to evidence and references

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionVerify prior authorization requirements and document medical necessity per InterQual and the member's plan before scheduling TMJ surgical procedures.

SourceLink

On This Page

Listed explicitly as unproven and not medically necessary.

Unproven services: Epigenetic appliances (e.g., Homeoblock, DNA Daytime/Nighttime appliance, Advanced Lightwire Functional [ALF] appliances)

Listed explicitly as unproven and not medically necessary.

Surgical intervention (including orthognathic or open joint surgery) is indicated only after failure of nonsurgical therapy and when pain and/or dysfunction are moderate to severe; not indicated for asymptomatic or minimally symptomatic patients.

AAOMS Parameters specify surgery only after nonsurgical therapies are ineffective and when symptoms are moderate to severe.

Refer to FDA product codes LZD, MPI (PMAs) and BXB (PMNs) for device listings.

Note

Benefit plan conformity required

Benefit plan terms and any applicable federal or state contractual requirements take precedence if they conflict with this policy. Always verify plan-specific provisions before rendering services.

In the event of a conflict, federal, state or contractual requirements govern.
Check the member's plan documents for exclusions, limits, and prior authorization requirements.

Documentation Required

Document applicable plan provisions

Document and reference the applicable plan provisions, laws, or regulations that support coverage determinations. When submitting requests or claims, include citations to the member's benefit language when relevant.

Reference federal/state/contractual benefit provisions when they affect coverage decisions.
Include plan citations with prior authorization requests and appeals as applicable.

Prior Authorization

Conservative-first treatment approach

Start treatment with conservative, reversible therapies whenever clinically appropriate. Surgery or irreversible procedures should be considered only after adequate trials of conservative management have failed.

Conservative therapies include NSAIDs, soft diet, jaw rest, moist heat, physical therapy, occlusal splints, muscle relaxants, injectable therapies (when indicated).
Surgical intervention is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe.

Injection rationaleInjections or dry needling relax muscle fibers, allow lengthening, and remove metabolite waste to interrupt the pain–tension cycle; agents used include corticosteroid, dextrose or saline.

Arthrocentesis — definition of TMJ lavage/aspiration and injection procedures

DefinitionTMJ lavage/aspiration and/or injection procedure (arthrocentesis) performed to remove inflammatory debris and irrigate the joint.

PurposePotentially improves pain and maximum mouth opening by mechanically removing debris and permitting intra-articular therapy.

Clinical reportingRandomized trials and network meta-analyses report arthrocentesis outcomes at multiple timepoints (e.g., 1–6 months) and often in combination with intra-articular injections such as PRP or HA.

Arthrogenous vs Myogenous TMD — distinction

Arthrogenous TMDDisorders originating in the joint (e.g., TMJ osteoarthritis, internal derangement); often assessed for pain and maximum mouth opening outcomes in arthrogenous-focused studies.

Myogenous TMDDisorders originating in the masticatory muscles (e.g., myofascial pain); management often emphasizes physical therapy, splints, and needling therapies.

Implication for treatmentSystematic reviews and network meta-analyses stratify outcomes by arthrogenous vs myogenous status when evaluating injections, splints, and minimally invasive procedures.

Jaw mobility mechanical stretching devices — definition and examples

DefinitionDevices designed to mechanically stretch and mobilize the mandible to treat mandibular hypomobility or trismus.

ExamplesTheraBite Jaw Motion Rehabilitation System; Jaw Dynasplint System; OraStretch Press Jaw Motion Rehab System; Therapacer Jaw Mobilizer.

Intended useUsed for passive rehabilitation and prolonged-duration stretching to improve jaw range of motion; evidence quality for efficacy is limited per policy reviews.

Epigenetic appliances — definition and updated examples

DefinitionIntraoral functional or occlusal appliances purported to modify craniofacial growth or jaw relationships by applying pressure when worn (similar in appearance to orthodontic retainers).

Examples (updated)Homeoblock, DNA appliances, Advanced Lightwire Functional (ALF) appliances (ALF explicitly added to examples).

Claims and evidenceThese appliances are purported to affect craniofacial growth and to treat conditions such as TMJ disorders, sleep apnea, and headaches; current policy notes insufficient high-quality evidence to support efficacy.