UnitedHealthcare TMJ Coverage Update

Coverage and Medical Necessity Criteria

inv-01: Non-surgical proven medically necessary services

Covered when criteria for medical necessity are met per InterQual clinical criteria (surgical) or as listed:

Non-surgical proven medically necessary services: Arthrocentesis; Intra-articular injections of corticosteroids; Physical therapy; Trigger point injections; Occlusal splint (stabilization and repositioning splints)

Listed as proven and medically necessary for treating TMJ disorders

inv-02: Surgical TMJ procedures (conditional)

Surgical services considered medically necessary in certain circumstances per referenced clinical criteria:

Surgical TMJ procedures: Arthroscopy, Temporomandibular Joint (TMJ); Arthroplasty, TMJ; Discectomy, TMJ; Reconstruction, TMJMedical necessity as defined by InterQual CP: Procedures

Refer to InterQual for specific clinical criteria and indications; prior authorization per plan/InterQual processes may be required

inv-03: Unproven / Not medically necessary

Services considered unproven and not medically necessary due to insufficient evidence:

Unproven/not medically necessary services: Biofeedback; Craniosacral manipulation/therapy; Multiple occlusal splints (e.g., daytime and nighttime splints, maxillary and mandibular splints); Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System; Jaw Dynasplint System); Epigenetic appliances (e.g., Homeoblock, Advanced Lightwire Functional [ALF] appliances)

Listed as not medically necessary due to insufficient evidence of efficacy and safety

inv-04: General coverage stance and pathway

Covered when following conservative-first approach and when therapies meet plan and applicable InterQual criteria

Conservative-first: Initial treatment should be conservative, reversible, and evidence-based per professional guidance (AADOCR); surgical intervention is indicated only when nonsurgical therapy has been ineffective and dysfunction is moderate to severe per AAOMS.

See InterQual CP: Procedures and member-specific benefit plan for specific authorization requirements.

Jaw mobility mechanical stretching devices and epigenetic appliances are listed as not medically necessary due to insufficient evidence of efficacy and safety. Examples of jaw mobility devices include systems intended for prolonged passive stretching or rehabilitation of mandibular hypomobility. The 05/01/2025 policy revision explicitly replaced prior wording to identify these as jaw mobility mechanical stretching devices (e.g., Therabite Jaw Motion Rehabilitation System; Jaw Dynasplint System) and updated the examples of epigenetic appliances.

Epigenetic appliances are intraoral devices that resemble orthodontic retainers and are proposed to expand the jaws by applying overnight pressure; the policy states there is no quality evidence supporting their effectiveness for TMJ disorders and therefore they are considered not medically necessary.

The policy lists several therapies and device categories as unproven and not medically necessary for treating temporomandibular joint disorders due to insufficient high-quality evidence. These include biofeedback and craniosacral manipulation/therapy, both of which lack quality evidence demonstrating benefit for TMJ conditions.

The policy also specifies that use of multiple occlusal splints (for example, daytime plus nighttime splints or simultaneous maxillary and mandibular splints) is unsupported because no published studies demonstrate a benefit from more than one splint used at the same time.

In addition, the policy identifies jaw mobility mechanical stretching devices and epigenetic appliances as device categories regarded as unproven; the revision on 05/01/2025 clarifies examples and adds devices such as Advanced Lightwire Functional (ALF) appliances to the list of epigenetic appliance examples.

The policy provides specific examples of services considered unproven, noting that biofeedback and craniosacral therapy are not supported by quality evidence for TMJ treatment.

It also calls out the absence of evidence for benefit when more than one occlusal splint is used concurrently: there are no published studies addressing treatment of TMJ disorders with more than one splint at a time, and therefore multiple splints are considered unproven.

For jaw mobility devices, the policy cites limited and inconclusive literature, including small studies and poor compliance, and summarizes examples of devices studied (e.g., Therabite, Jaw Dynasplint) as having insufficient evidence to support routine use for TMD.

Examples of jaw mobility mechanical stretching devices referenced in the policy include the Therabite Jaw Motion Rehabilitation System and the Jaw Dynasplint System; other commercial names described in the Description of Services include OraStretch Press and Therapacer Jaw Mobilizer. The evidence base for these devices is limited by small sample sizes, short follow-up, and low compliance in trials.

Examples of epigenetic appliances cited include Homeoblock DNA (daytime/nighttime appliance) and the Advanced Lightwire Functional (ALF) appliances. The policy states that a review of the medical literature did not identify quality evidence to support the efficacy of epigenetic appliances for TMJ disorders.

Procedure and Billing Codes

Surgical and procedural CPT codes referencedCPT

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 17

1/2

Additional CPT and HCPCS codes referencedmixed

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

Provider Responsibilities and Operational Guidance

Prior Authorization

Verify member benefits and other policies

Verify member-specific benefits, plan documents, and applicable federal or state contractual requirements before seeking prior authorization or performing services. Benefit coverage for health services is determined by the member's benefit plan and applicable laws; a listed code or service in this policy does not guarantee coverage or payment.

Verify member benefits and prior authorization requirements in the member's plan before scheduling services
Confirm whether federal or state mandates alter coverage for the specific member
Check related UnitedHealthcare Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines when InterQual criteria are not applicable

Documentation Required

Documentation and decision context

Document clinical decision-making, prior conservative treatments tried, treatment response, and rationale for escalation to procedures or surgery. Reference InterQual criteria when applicable and retain records sufficient to support medical necessity in the event of utilization review or claim audit.

Clinical Background

Temporomandibular disorders (TMD) comprise a heterogeneous group of conditions affecting the temporomandibular joint and surrounding masticatory muscles, commonly presenting with jaw pain, limited range of motion, and joint noises. Many patients improve with conservative, reversible treatments such as rest, NSAIDs, soft diet, heat, physical therapy, and occlusal splints.

The policy endorses a conservative-first approach consistent with professional guidance: initial management should favor conservative, reversible, evidence-based therapies. For patients who fail nonsurgical therapy or who have moderate to severe dysfunction, injection therapies or surgical interventions (e.g., arthroscopy, arthroplasty, discectomy, reconstruction) may be considered when medical necessity criteria are met per InterQual.

Key Definitions and Device Examples

inv-20: Occlusal splint — definition and variants

DefinitionRemovable intraoral appliance (eg, stabilization/night guard or mandibular repositioning splint) intended to reduce or eliminate clenching/bruxism and to keep or reposition the jaw in a more relaxed position; made of various materials and may cover some or all teeth of an arch.

Common variantsStabilization (hard) splint, anterior repositioning splint, mini anterior splints, night guard (occlusal guard).

Intended effectsReduce tooth grinding/clenching, decrease muscle tension and pain, improve mouth opening and reduce TMJ noises depending on device type and TMD origin.

Evidence notesNetwork meta-analysis (48 RCTs) and meta-analyses (eg, 33 RCTs for stabilization splints) show short-term benefit for some splint types; long-term effects may equalize with other therapies.

inv-21: Jaw mobility devices / Epigenetic appliances — definition and example devices

Policy Revision History

2025-05-01policy_revisionLatest

Policy revised to update the list of services considered unproven/not medically necessary: wording changed to explicitly list 'jaw mobility mechanical stretching devices' (examples: TheraBite Jaw Motion Rehabilitation System; Jaw Dynasplint System), examples of epigenetic appliances were revised and Advanced Lightwire Functional (ALF) appliances were added; supporting sections (Description of Services, Clinical Evidence, References) were updated and prior version CS195KY.08 archived.

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Treatment of Temporomandibular Joint Disorders (TMJ/TMD) — Kentucky