ModifiedUnitedHealthcarePolicy CS195PA.G

Treatment of Temporomandibular Joint Disorders (for Pennsylvania Only)

Medical policy governing coverage and medical necessity of non‑surgical and surgical treatments for temporomandibular joint disorders for UnitedHealthcare members in Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for Pennsylvania Only)

Policy CodePolicy CS195PA.G

Change TypeRevisions to unproven device examples and supporting information (material)

Effective DateApril 1, 2025

Next Review Date

Key ActionDocument that conservative, reversible treatments were tried and unsuccessful before pursuing injections or surgery and check plan-specific prior authorization and InterQual requirements.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary services to replace 'passive rehabilitation therapy devices' and 'low-load prolonged-duration stretch devices' with 'jaw mobility mechanical stretching devices (e.g., Therabite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System)'.

Revised list of examples of epigenetic appliances; added 'Advanced Lightwire Functional (ALF) appliances'.

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

5 servicesMedically necessary non-surgical

5 examplesUnproven / not medically necessary

PAGeographic scope

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

04/01/2025Policy revision date

Coverage Criteria for TMJ Treatments

Medically Necessary Non-surgical Services

Covered when clinically indicated per policy:

Non-surgical proven therapies: Arthrocentesis; intra-articular injections of corticosteroids; occlusal splint (stabilization and repositioning splints); physical therapy; trigger point injections.

These non-surgical services are listed as proven and medically necessary for treating TMJ disorders.

Surgical Services (refer to InterQual)

Surgical TMJ services are covered in certain circumstances per clinical criteria:

Surgical procedures referenced to InterQual: Arthroscopy, discectomy, reconstruction, and arthroplasty of the temporomandibular joint are recognized as medically necessary in certain circumstances; refer to InterQual® CP and InterQual® Client Defined content for medical necessity clinical coverage criteria.

Provider must refer to InterQual criteria for detailed surgical indications.

Unproven / Not Medically Necessary

Not medically necessary due to insufficient evidence:

Unproven therapies: Biofeedback; craniosacral manipulation/therapy; jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System); multiple occlusal splints (e.g., daytime and nighttime or maxillary and mandibular appliances used concurrently); epigenetic appliances (e.g., Homeoblock™, DNA® Daytime/Nighttime appliance, Advanced Lightwire Functional (ALF) appliances) are considered unproven and not medically necessary due to insufficient evidence of efficacy.

List is not all-inclusive; see policy for cross-references to related drug/device policies.

Coverage rationale and criteria group

Summary coverage stance based on reviewed evidence and society guidance

Conservative-first: Initial treatment should be conservative, reversible, and evidence-based (education/counseling, occlusal splint therapy, physical therapy, therapeutic exercise) consistent with AADOCR and AAOMS guidance.

Conservative measures often equal or exceed invasive options in short-term symptom relief and carry lower risk.

Minimally invasive options: Minimally invasive procedures — arthrocentesis and intra-articular injections (corticosteroids, hyaluronic acid, platelet-rich plasma) — have low to moderate quality evidence for short- and intermediate-term pain reduction and improved mouth opening and may be considered when conservative therapy is insufficient.

Network meta-analyses and RCTs show benefit though evidence quality varies; arthrocentesis with lavage contributes to improved MMO.

Trigger point/needling therapies: Needling therapies (dry needling, local anesthetic injections, botulinum toxin-A, PRP) demonstrate some short- and intermediate-term benefit for myofascial pain but overall evidence quality is low; consider as adjuncts when appropriate.

The policy identifies specific therapies considered unproven and not medically necessary for TMJ disorders due to insufficient evidence. These include biofeedback, craniosacral manipulation/therapy, jaw mobility mechanical stretching devices (e.g., TheraBite® Jaw Motion Rehabilitation System, Jaw Dynasplint® System), multiple occlusal splints (for example daytime and nighttime splints or simultaneous maxillary and mandibular splints), and epigenetic appliances (for example Homeoblock™, DNA® daytime/nighttime appliances, and Advanced Lightwire Functional (ALF) appliances).

Craniosacral manipulation/therapy and epigenetic appliances are explicitly noted as unsupported by quality evidence in the literature review. The policy states that no quality evidence was identified to support craniosacral manipulation for TMJ disorders, and likewise that epigenetic appliances lack sufficient evidence to establish a treatment effect on health outcomes.

FDA regulatory status and approvals are provided for informational purposes only; FDA approval alone is not a basis for coverage under this policy.

The policy lists the following as examples of therapies considered unproven or not medically necessary for treating TMJ disorders: biofeedback; craniosacral manipulation/therapy; jaw mobility mechanical stretching devices (for example TheraBite® and Jaw Dynasplint®); multiple occlusal splints (e.g., concurrent daytime and nighttime or maxillary and mandibular splints); and epigenetic appliances (for example Homeoblock™, DNA® appliances, and ALF appliances). This enumeration is not all‑inclusive.

Jaw mobility mechanical stretching devices (examples include the TheraBite® Jaw Motion Rehabilitation System and the Jaw Dynasplint® System) are considered unproven because published studies have generally been small, had short follow‑up, suffered large losses to follow‑up, or produced inconclusive or unfavorable results. Reported compliance with these devices is low in several studies, and available evidence does not establish a clear beneficial impact on clinical outcomes.

Coding and Regulatory Information

Referenced CPT procedure codes (group 1)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 (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance.
20606	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon 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

Referenced CPT and HCPCS codes (group 2)mixed

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).
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.

FDA product codes (informational)mixed

LZD	FDA product code referenced for TMJ prostheses
MPI	FDA product code referenced for TMJ prostheses
BXB	FDA product code referenced for continuous passive motion (CPM) machines

FDA safety communication date — March 2023 note

FDA safety communication dateMarch 2023

ContextFDA issued a safety communication in March 2023 regarding jaw remodeling devices for adults (informational only).

Reference noteFDA communications are informational and do not by themselves determine coverage under this policy.

Provider Actions, Prior Authorization, and Documentation

Billing Rule

Code listing is reference only

The list of procedure and diagnosis codes in this policy is provided for reference only and may not be all inclusive. 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. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other policies and guidelines may apply.

See Applicable Codes section for CPT and HCPCS code listings; review plan/contract for coverage determination.

Denial Risk

Insufficient evidence and low compliance risk for jaw stretching devices

Jaw mobility mechanical stretching devices (for example, Jaw Dynasplint, TheraBite and similar devices) are considered unproven due to insufficient high‑quality evidence of efficacy and safety. Published studies are limited by small sample sizes, short follow‑up, high loss‑to‑follow‑up and poor compliance. Low device compliance in trials reduces the ability to demonstrate clinical benefit and increases risk of non‑effectiveness.

Background and Scope

Temporomandibular disorders (TMD) encompass conditions affecting the temporomandibular joint and the surrounding masticatory musculature, and commonly present with jaw pain, limited mouth opening, joint noises, and impaired jaw function. Many cases respond to conservative, reversible measures (for example activity modification, NSAIDs, soft diet, heat, physiotherapy, occlusal splints, and pharmacologic therapies); persistent or severe cases may require minimally invasive procedures (such as arthrocentesis or intra‑articular injections) or, in select circumstances, surgical intervention per referenced InterQual criteria.

Definitions and Key Terms

Occlusal splint — definition and purpose

DefinitionA stabilization or mandibular repositioning device (night guard) intended to reduce clenching/bruxism and reposition the jaw; may cover some or all teeth of an arch.

PurposeUsed to treat myofascial pain dysfunction and TMJ disorders by reducing/eliminating clenching or bruxism and maintaining or repositioning the jaw in a more relaxed position.

FormsSplint therapy includes stabilization splints (night guards) and mandibular repositioning splints/devices made of various materials.

Myofascial trigger point — definition and clinical note

DefinitionFocal knot in a band of skeletal muscle caused by acute or repeated microtrauma, commonly seen in TMJ disorders.

Clinical note

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for Pennsylvania Only)

Policy CodePolicy CS195PA.G

Change TypeRevisions to unproven device examples and supporting information (material)

Effective DateApril 1, 2025

Next Review Date

Key ActionDocument that conservative, reversible treatments were tried and unsuccessful before pursuing injections or surgery and check plan-specific prior authorization and InterQual requirements.

SourceLink

On This Page

Evidence from trials and meta-analyses is limited by small samples and variable protocols.

Devices with insufficient evidence: Jaw mobility mechanical stretching devices, epigenetic appliances, craniosacral manipulation, and biofeedback lack high-quality evidence of efficacy or have compliance concerns and are considered unproven or limited in effectiveness.

Multiple systematic reviews and RCTs report small sample sizes, heterogeneity, or low compliance leading to inconclusive or unfavorable findings.

Examples with documented low compliance: Jaw Dynasplint, TheraBite.
Clinical implication: low adherence may lead to treatment failure and is a denial-risk factor when justification of medical necessity relies on device use.

Note

Conservative-first, reversible treatment recommended

Conservative, reversible, evidence‑based therapies should be attempted before irreversible or surgical interventions. Recommended initial treatments include NSAIDs, soft diet, jaw rest, moist heat, splints, physical therapy, muscle relaxants, and other conservative measures. Injection therapy or surgery should be considered only after appropriate conservative management has failed.

Follow a conservative‑first approach consistent with professional society recommendations.
Escalation pathway: conservative care → consider injections (e.g., arthrocentesis, trigger point injections) → consider surgery only if conservative therapy fails and criteria met.

Documentation Required

Pre‑surgical documentation required

Document in the medical record failure of nonsurgical therapy prior to elective TMJ surgical procedures. Records should include types and durations of conservative treatments tried, response to therapy, and rationale for proceeding to surgery. For orthognathic procedures associated with TMJ pathology, document that non‑surgical therapies were attempted and pretreatment therapeutic goals.

Required pre‑surgical documentation: list of conservative modalities tried, dates/duration, objective measures of function or pain, and clinician rationale for surgery.
When applicable, reference InterQual criteria for specific surgical procedures to ensure medical necessity documentation meets third‑party tool requirements.

Note

Follow governing benefit plan terms

This policy is intended to assist in interpreting UnitedHealthcare standard benefit plans but is informational only. Coverage decisions must follow the governing federal, state, and contractual benefit plan terms; in the event of a conflict, those terms govern. Check applicable plan, contract, and any state‑specific requirements (Pennsylvania PARP exceptions) before rendering coverage determinations.

Policy does not replace plan, contract, or legal requirements; always verify member’s benefit plan and state mandates before approval.
For Pennsylvania: this policy applies to Pennsylvania only; requests not meeting PARP criteria will be evaluated case‑by‑case per Pennsylvania Code, Title 55, Chapter 1101.

Prior Authorization

Prior authorization and use of external criteria

UnitedHealthcare may use third‑party clinical decision support tools (for example, InterQual®) to assist in administering benefits. Prior authorization requirements and medical necessity determinations may be based on plan contract language and these tools. Providers should verify whether prior authorization is required by the member’s plan and submit documentation that aligns with the applicable clinical criteria.

Prior authorization: determined by the member’s contract and may reference InterQual or other client‑defined criteria.
Action for providers: check plan authorization requirements and include documentation consistent with the referenced criteria when submitting requests.

Injections (dry needling or with corticosteroid, dextrose, or saline) relax muscle fibers, allow lengthening, remove metabolite waste, and help break the pain–tension cycle.

RelevanceAssociated with myofascial pain of the masticatory muscles and may be targeted by trigger point therapies.

Arthrocentesis — definition and intended use

DefinitionArthrocentesis: TMJ lavage/aspiration and/or injection of an intermediate joint or bursa to remove debris and inflammatory products; used diagnostically and therapeutically.

Intended useConsidered a minimally invasive procedure with evidence for short- and intermediate-term improvement in mouth opening and pain when conservative therapy is insufficient.

Procedural noteMay be performed with or without adjuncts (e.g., hyaluronic acid, corticosteroids, PRP) per cited studies and network meta-analyses.

Craniosacral manipulation — definition of complementary therapy

DefinitionCraniosacral manipulation (craniosacral therapy) is a complementary health approach using palpation of cranial structures and selective pressures intended to produce therapeutic effects via purported cranial rhythmic movement.

Policy noteConsidered a complementary therapy and designated unproven/not medically necessary for TMD in this policy due to insufficient quality evidence.

Mechanism premisePremise attributes small rhythmic cranial bone movements to cerebrospinal fluid or arterial pressure and applies selective pressure to influence these dynamics.

Occlusal splint types — list of splint types (HSS, SSS, prefabricated, mini-anterior, anterior repositioning)

Included typesHard stabilization splint (HSS)

Included typesSoft stabilization splint (SSS)

Included typesPrefabricated splint

Included typesMini-anterior splint

Included typesAnterior repositioning splint (ARS)

Injectables / needling therapies — definitions and examples (intraarticular injections, PRP, dry needling, local myofascial injections)

DefinitionIntraarticular injections: injections into the TMJ (e.g., corticosteroids, hyaluronic acid) used to reduce inflammation and pain.

Biologic injectablesPlatelet-rich plasma (PRP) — evaluated in trials and network meta-analyses for pain and mouth-opening outcomes.

Needling therapiesDry needling and wet needling (local anesthetic, botulinum toxin-A) used for myofascial trigger points and masticatory muscle pain.

Clinical contextEvidence shows some short- and intermediate-term benefits for injectables and needling therapies, but overall quality of evidence is low to very low.

TMJ prostheses (FDA) — Class III device description and PMA note

FDA classificationTMJ prostheses are regulated as Class III medical devices.

Regulatory requirementClass III TMJ prostheses require premarket approval (PMA); product codes referenced include LZD and MPI.

Coverage noteFDA regulatory status is informational only; FDA approval alone is not a basis for coverage under this policy.

CPM machines (FDA) — Class II device description (product code BXB)

FDA classificationContinuous passive motion (CPM) machines for jaw therapy are classified by the FDA as Class II devices (product code BXB).

Regulatory contextClass II devices meet General Controls and Performance Standards as established by the FDA.

Informational useFDA device listings are informational and do not by themselves determine coverage decisions under this policy.

Jaw remodeling devices (FDA safety communication) — mention of March 2023 FDA communication regarding jaw remodeling devices for adults

FDA communication topicJaw remodeling devices for adults

DateMarch 2023 (FDA issued a safety communication regarding these devices).

Policy implicationThis FDA safety communication is noted for informational purposes; FDA information alone does not establish coverage.