ModifiedUnitedHealthcarePolicy CS195KY.09

Treatment of Temporomandibular Joint Disorders (Kentucky only)

Kentucky-only medical policy describing coverage stance and evidence for non‑surgical and surgical treatments for temporomandibular joint disorders, and listing applicable procedure and supply codes; applies to UnitedHealthcare members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (Kentucky only)

Policy CodePolicy CS195KY.09

Change TypeRevised examples of unproven devices and appliances

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionRefer to InterQual® criteria for medical necessity when requesting prior authorization for TMJ surgical procedures.

SourceLink

POLICY UPDATE CHANGES

Replaced specific examples of passive rehabilitation and low-load prolonged-duration stretch devices with the broader term 'jaw mobility mechanical stretching devices (e.g., Therabite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System)'.

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

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

5Non-surgical proven and medically necessary services

4TMJ surgical procedures referenced to InterQual®

~40CPT/HCPCS codes listed

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.

KYPolicy applies to state

insufficientEvidence for listed unproven therapies

Coverage Criteria for TMJ Disorders

Surgical TMJ procedures (InterQual®-based)

Surgical temporomandibular joint (TMJ) procedures are covered only when the InterQual® clinical criteria for the specific procedure are met.

ALL of the following

Procedure is one of the following: arthroplasty, arthroscopy, discectomy, or reconstruction of the temporomandibular joint (TMJ).
Refer to the InterQual® CP: Procedures list for procedure definitions and coding.
Documentation demonstrates failure of or contraindication to appropriate non-surgical, conservative therapy as defined elsewhere in this policy or per InterQual® guidance.
Conservative therapies include but are not limited to physical therapy, occlusal splint therapy, intra-articular injections, and other non-surgical proven services.
Clinical presentation includes significant pain and/or dysfunction attributable to TMJ pathology that has not responded to conservative management and where surgical intervention is expected to improve health outcomes.
Surgery is not indicated for asymptomatic or minimally symptomatic patients.
Medical records and imaging support the diagnosis and anatomic/functional indications for the selected TMJ surgical procedure.
Include operative plans, imaging reports, prior treatment notes, and symptom severity assessments.
All required prior authorization and procedural documentation requirements are completed per payer policy and InterQual® operational guidance.
Failure to obtain prior authorization may result in denial or retrospective review.

Applicable Procedure and Supply Codes

Procedure CPT codes (part 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

Procedure CPT and HCPCS codes (part 2) and DMEmixed

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 Actions, Authorization, and Documentation

Prior Authorization

InterQual® Required for TMJ Surgery

InterQual® clinical criteria are required to determine medical necessity for TMJ surgical procedures. Prior authorization decisions for arthroplasty, arthroscopy, discectomy, reconstruction, and other TMJ surgeries will be based on meeting InterQual® CP: Procedures criteria.

InterQual® required for TMJ surgery (arthroplasty, arthroscopy, discectomy, reconstruction)

Note

Device Approval Note and Prior Authorization Implication

FDA device approval is informational only and does not guarantee coverage. Verify FDA approval status for Class II/III devices (e.g., TMJ prostheses—Class III; CPM machines—Class II) and be aware that FDA status may affect prior authorization or required documentation. Review the FDA PMA/PMN databases and the policy’s examples when submitting requests.

Check FDA approval status for TMJ prostheses (product codes LZD, MPI) and CPM devices (product code BXB).
FDA approval alone is not a basis for coverage; prior authorization may still be required.

Background and Scope

Temporomandibular disorders (TMD) are a heterogeneous group of conditions affecting the temporomandibular joint and the surrounding masticatory muscles, commonly presenting with jaw pain, limited mouth opening or range of motion, and joint noises. Initial management is generally conservative and reversible—examples include education, activity modification (soft diet, jaw rest), nonsteroidal anti-inflammatory drugs, thermal modalities, physical/manual therapy and therapeutic exercises, occlusal splints, and behavioral interventions. When conservative care fails to relieve moderate to severe pain or dysfunction, targeted injections or surgical procedures may be considered per the policy and InterQual® criteria.

Key Definitions

inv-19: Occlusal splint — definition and intended use

DefinitionA stabilization or mandibular repositioning device (also called a night guard or occlusal guard) intended to reduce or eliminate clenching/bruxism and to keep or reposition the jaw in a more relaxed position; splints may cover all or some teeth of an arch.

Intended useTreat myofascial pain dysfunction and temporomandibular disorders by reducing parafunctional loading and repositioning the mandible to relieve pain and improve function.

Types/examplesStabilization (hard) splints, soft stabilization splints, mandibular repositioning splints (anterior repositioning splints), prefabricated and custom appliances.

Clinical noteEvidence ranges from very low to moderate quality across splint types; multimodal therapy (counseling plus hard stabilization splint) may provide maximal improvement per network meta-analysis.

inv-20: Myofascial trigger point — definition and relevance to treatments

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (Kentucky only)

Policy CodePolicy CS195KY.09

Change TypeRevised examples of unproven devices and appliances

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionRefer to InterQual® criteria for medical necessity when requesting prior authorization for TMJ surgical procedures.

SourceLink

On This Page

Documentation Required

Code Listing Disclaimer

Listing of codes in this policy is for reference only and does not imply that a service is covered or eligible for reimbursement. Benefit coverage is determined by the member’s specific plan and applicable laws; other policies and guidelines may apply.

Inclusion of a code does not guarantee coverage or payment.
Confirm member benefits and applicable coverage rules before billing.

Denial Risk

Denial Risk for Unproven / Not Medically Necessary Devices

Certain devices and appliances are considered unproven or not medically necessary and are at high risk for denial. Examples include jaw mobility mechanical stretching devices (e.g., Therabite, Jaw Dynasplint) and certain epigenetic appliances (including Advanced Lightwire Functional (ALF) appliances). Submit supporting clinical justification if requesting coverage for devices outside established criteria.

Denial risk for jaw mobility mechanical stretching devices (e.g., Therabite, Jaw Dynasplint).
Denial risk for certain epigenetic appliances, including ALF appliances.

Documentation Required

Documentation and Claims Note

Document clinical rationale, prior treatments, and therapeutic goals in the medical record and prior authorization submission. Include details of conservative therapies tried, duration, patient response, functional limitations, pain severity, and specific goals for treatment. Claims will be adjudicated based on member benefits and documented medical necessity; the code list in this policy is not a substitute for required documentation.

Document conservative therapy attempts, dates, frequency, and outcomes (e.g., physical therapy, splints, injections).
State pretreatment therapeutic goals and objective measures of dysfunction/pain.
Ensure claim submissions reference member benefit limitations and supporting clinical documentation.

Step Therapy

Conservative-First, Stepwise Pathway

A stepwise, conservative-first pathway is expected. Conservative, reversible, evidence-based modalities should be attempted and documented prior to escalation to invasive or surgical interventions. InterQual® functions as the decision tool for escalation to surgery and is consistent with professional society guidance.

Conservative therapies first: physical therapy, occlusal splints, injections, reversible modalities.
Document goals and prior therapies before requesting surgical authorization.
InterQual® is used as the pathway/step tool to determine eligibility for surgery.

DefinitionA focal knot in a band of skeletal muscle caused by acute or repeated microtrauma, commonly present in temporomandibular disorders.

Relevance to TMD treatmentTrigger points contribute to jaw muscle pain and dysfunction; treating them can help break the pain–tension cycle and improve muscle length and function.

Treatment modalitiesDry needling and trigger point injections (e.g., corticosteroid, dextrose, or saline) which relax muscle fibers and remove metabolite waste.

inv-21: Arthrocentesis — definition and associated procedure codes

DefinitionJoint lavage/aspiration and/or injection of the temporomandibular joint (intermediate joint/bursa), performed with or without image guidance.

Associated CPT codes20605 (arthrocentesis without ultrasound guidance); 20606 (with ultrasound guidance, with permanent recording and reporting).

PurposeUsed to irrigate the joint, remove inflammatory mediators, and deliver intra-articular medications to relieve pain and improve function.

inv-22: Conservative, reversible modalities — definition and examples (education, occlusal splints, PT, manual therapy, behavioral interventions)

DefinitionNon-surgical, reversible therapies that do not produce irreversible anatomic changes and are used as first-line management for TMD.

Core examplesEducation/counseling, occlusal splint therapy, physical therapy (including therapeutic exercises and manual therapy), behavioral interventions (e.g., CBT, biofeedback).

Clinical roleRecommended as initial management; multimodal combinations (e.g., counseling plus hard stabilization splint, or adding physical/manual therapy) have RCT/systematic review evidence of short- to mid-term benefit.

Practice notePretreatment therapeutic goals should be individualized and documented; surgery is reserved for cases where conservative therapy is ineffective and pain/dysfunction remain moderate to severe.