ModifiedUnitedHealthcarePolicy CSNCT0079.08

Treatment of Temporomandibular Joint Disorders (for North Carolina Only)

This policy governs medical necessity and coverage of nonsurgical and surgical treatments for temporomandibular joint disorders for UnitedHealthcare members in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for North Carolina Only)

Policy CodePolicy CSNCT0079.08

Change TypeRevised exclusions listcode removalsadded documentation language

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain and provide complete medical record documentation showing prior conservative and minimally invasive therapies when seeking prior authorization for major TMJ surgery.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary services; removed 'craniosacral manipulation/therapy'.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria for coverage.

Removed CPT codes 21089 and 21499 from applicable codes.

5nonsurgical services proven

3InterQual sources referenced

multipleprocedure codes listed

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low–moderateevidence quality

Coverage Criteria for TMJ Treatments

inv-01: Nonsurgical treatments - covered

Covered when clinically indicated:

Proven nonsurgical TMJ services: Arthrocentesis; Intra-articular injections of corticosteroids; Trigger point injections; Physical therapy; Occlusal splint (stabilization and repositioning)

Listed as proven and medically necessary for treating TMJ disorders.

inv-02: Surgical treatments - covered with criteria

Surgical TMJ services are covered only when InterQual clinical criteria are met:

Surgical TMJ services: Arthroscopy; Discectomy; Reconstruction; Arthroplasty/Total joint replacement of the TMJ when InterQual clinical criteria are satisfied

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

inv-03: Initial (conservative) therapy

Covered when ALL of the following are met

Initial conservative care: Initiate treatment with conservative, reversible, evidence-based modalities (eg, education, soft diet, jaw rest, NSAIDs, physical therapy, occlusal splinting) unless specific, justifiable indications support immediate invasive therapy.

Consistent with AADOCR recommendation to start with conservative care and because many TMDs improve or resolve over time.

inv-04: Indications for surgical intervention (arthroplasty/total joint replacement)

Surgical procedures are considered when ALL of the following are met

Surgical indication: Nonsurgical and minimally invasive therapies have been attempted and proven ineffective AND the patient has moderate to severe pain and/or dysfunction AND pretreatment therapeutic goals have been determined individually; surgery is not indicated for asymptomatic or minimally symptomatic patients.

Reflects AAOMS parameters of care and position statements reserving arthroplasty and total joint replacement for patients who fail less invasive therapies.

inv-05: Minimally invasive and adjunctive therapies — evidence summary

Coverage stance informed by summarized evidence (mixed quality)

Corticosteroid injections and arthrocentesis: Systematic reviews and RCTs show corticosteroid injections alone or combined with arthrocentesis can reduce TMJ pain; arthrocentesis with lavage improves maximum mouth opening (MMO) and pain, though superiority of injectables over lavage alone is not clearly established.

See Liapaki et al. (2021) and Al-Moraissi et al. (2020a).

Trigger point injections / needling: Needling therapies (eg, local anesthetic, dry needling, PRP, BTX‑A) demonstrate some short- and intermediate-term benefit for pain and MMO, but the overall quality of evidence is low to very low and conclusions are tentative.

See Saglam RCT and Al‑Moraissi network meta‑analysis (2020b).

Physical therapy and manual therapy: RCTs and systematic reviews indicate that adding physical/manual therapy to splint therapy and education improves pain and MMO in the midterm; exercise therapy may be equivalent to occlusal splint for some outcomes.

See Romeo et al. (2024), Asquini et al. (2022), Herrera‑Valencia et al. (2020).

inv-06: Treatment sequencing

Covered when ALL of the following are met

Initial management: Begin with conservative, reversible, evidence‑based modalities because many TMDs improve or resolve over time; document trial and response in the medical record.

AADOCR recommends conservative initial therapy.

Progression to invasive therapies: Progress to minimally invasive injections or arthrocentesis and reserve surgical interventions (eg, arthroplasty, total joint replacement, orthognathic surgery) for patients who have failed appropriate conservative and minimally invasive treatments and who have moderate to severe pain or dysfunction.

AAOMS position and parameters of care require failed conservative care and documented severity prior to surgery.

The policy lists biofeedback among services considered unproven and not medically necessary for treating TMJ disorders due to insufficient evidence of efficacy. Biofeedback may be used for behavioral self‑regulation, but current high‑quality evidence is inadequate to support it as an isolated, effective treatment for TMJ conditions (see evidence summary and exclusion list).

Jaw mobility devices (passive mechanical stretching systems such as the TheraBite, Jaw Dynasplint, OraStretch Press, and Therapacer Jaw Mobilizer) are similarly listed as unproven and not medically necessary. These devices are intended for prolonged-duration mandibular stretching to address hypomobility, but studies are limited and inconclusive and adherence to prescribed use is frequently low, reducing the ability to demonstrate clinical benefit.

The policy specifically identifies multiple occlusal splints (for example, combinations of daytime and nighttime splints and maxillary plus mandibular appliances) as not medically necessary when used simultaneously, reflecting the lack of evidence supporting benefit from using more than one splint at the same time.

Epigenetic intraoral appliances (devices resembling orthodontic retainers that purport to expand the jaws by overnight pressure) are listed among unsupported therapies; the literature review failed to identify quality evidence that these appliances improve health outcomes for TMJ disorders.

Jaw mobility mechanical stretching devices are designated unproven and not medically necessary in this policy. The published studies are small, have short follow‑up or large loss to follow‑up, and most findings are inconclusive or unfavorable.

Adherence has been a consistent problem in trials evaluating these devices. For example, randomized feasibility and prevention studies reported poor adherence to devices such as the Jaw Dynasplint and no consistent improvement in maximum mouth opening or quality of life compared with conventional stretching, limiting the ability to demonstrate efficacy in typical TMJ populations.

This revision updated the policy's list of unproven and not medically necessary services. The change removed craniosacral manipulation/therapy from that list and updated supporting sections including Description of Services, Clinical Evidence, and References. The policy history notes these operational changes effective 06/01/2026.

The policy explicitly identifies the use of multiple occlusal splints—for example, simultaneous daytime and nighttime splints or concurrent maxillary and mandibular appliances—as not medically necessary. The statement reflects the absence of evidence that more than one splint worn concurrently provides additional clinical benefit for TMJ disorders.

Epigenetic appliances are listed as unproven because a review of the medical literature did not identify quality evidence supporting their efficacy for TMJ disorders. These intraoral devices, which resemble orthodontic retainers and are theorized to expand the jaws with overnight pressure, have not demonstrated improved health outcomes in available studies.

The policy consolidates several interventions as unproven and not medically necessary for TMJ disorders: biofeedback; jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint); multiple occlusal splints (daytime and nighttime, maxillary and mandibular used together); and epigenetic appliances. The rationale cited throughout the policy is insufficient or low‑quality evidence of efficacy and, for devices, frequent adherence problems that limit demonstrated clinical impact.

The 06/01/2026 revision updated this unproven/not medically necessary list and removed craniosacral manipulation/therapy from the exclusions; it also clarified documentation expectations and noted that providing medical records to assess criteria does not guarantee coverage.

Applicable Procedure, HCPCS, and Product Codes

Applicable CPT codes (procedures)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.
21110	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal.

1–10 of 17

1/2

Unlisted / miscellaneous CPT codes (may not be on NC Medicaid fee schedule)CPT

90901	Biofeedback training by any modality.
97039	Unlisted modality (specify type and time if constant attendance).
97139	Unlisted therapeutic procedure (specify).

HCPCS codes (DME / devices; some not on NC Medicaid fee schedule)HCPCS

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.

Removed CPT CodesCPT

21089	CPT code removed
21499	CPT code removed

FDA product codes (informational)mixed

LZD	FDA product code for temporomandibular joint prostheses (informational)
MPI	FDA product code for temporomandibular joint prostheses (informational)
BXB	FDA product code for continuous passive motion machines (informational)

Provider Actions, Prior Authorization, and Documentation Requirements

Documentation Required

Documentation Expectations for Surgical Requests

Certain temporomandibular joint (TMJ) surgical services require prior authorization and supporting medical records. Documentation must include a thorough history, physical examination, and results of pertinent diagnostic tests that demonstrate failure of conservative and/or minimally invasive therapies when surgery is being requested. Provision of records does not guarantee coverage.

Medical records must document relevant medical history, physical exam findings, and diagnostic test results.
For arthroplasty or total joint replacement requests, documentation should clearly show that conservative and minimally invasive therapies were attempted and were ineffective.
Failure to provide adequate documentation may result in denial or inability to confirm coverage.

Step Therapy

Conservative-First and Stepwise Surgical Approach

Use a conservative-first, stepwise approach before proceeding to injections or surgery. Initiate conservative, reversible, evidence-based modalities (e.g., medications, soft diet, jaw rest, physical therapy, occlusal splints, and other noninvasive treatments). If conservative care fails, minimally invasive procedures such as arthrocentesis or intra-articular injections may be considered prior to arthroplasty or total joint replacement.

Background and Scope

Temporomandibular disorders (TMDs) are a heterogeneous group of conditions affecting the temporomandibular joint and adjacent masticatory muscles, commonly causing pain, limited mouth opening, and joint noises. Many cases improve or resolve with conservative measures such as NSAIDs, soft diet, activity modification (jaw rest), heat, targeted physical therapy, and occlusal stabilization appliances.

Because symptomatology and progression vary, the policy emphasizes a conservative‑first approach: start with conservative, reversible, evidence‑based therapies and progress to injections, minimally invasive procedures, or surgery only when indicated. Surgical interventions (arthroplasty, total joint replacement, or other major procedures) are reserved for patients with persistent, moderate to severe pain or dysfunction after appropriate conservative and minimally invasive treatments have failed. Documentation of prior conservative therapy and objective findings (for example, changes in maximum mouth opening) is required to support consideration of more invasive interventions.

Definitions

Arthrocentesis — definition and purpose

DefinitionArthrocentesis (lavage): a minimally invasive procedure in which irrigants are injected into the TMJ to remove inflammatory mediators and intra‑articular adhesions and to improve joint mobility.

PurposeIntended to decrease TMJ pain and improve maximum mouth opening (MMO) by flushing debris, inflammatory cells, and matrix detritus from the joint space.

Clinical roleMay be used as a first‑line minimally invasive treatment for TMJ osteoarthritis when followed by an injectable; evidence shows it can improve pain and MMO over at least 6–12 months.

Occlusal splint — stabilization or mandibular repositioning devices

DefinitionOcclusal splint: a removable stabilization (night guard/occlusal guard) or mandibular repositioning device fabricated to cover some or all teeth of an arch.

Policy Revision History

2026-06-01policy_revisionLatest

Revised list of unproven and not medically necessary services (removed 'craniosacral manipulation/therapy'); updated clinical sections and supporting information; archived prior version CSNCT0079.07.

2026-06-01documentation_update

2026-06-01coding_change

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for North Carolina Only)

Policy CodePolicy CSNCT0079.08

Change TypeRevised exclusions listcode removalsadded documentation language

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain and provide complete medical record documentation showing prior conservative and minimally invasive therapies when seeking prior authorization for major TMJ surgery.

SourceLink

On This Page

Occlusal splints: Network meta‑analyses support short‑term benefit of stabilization and other splints for pain and MMO; multimodal therapy (eg, counseling plus hard stabilization splint) may provide greatest improvement, though long‑term differences often diminish.

See Al‑Moraissi and Kuzmanovic meta‑analyses.

Biofeedback: Current evidence is insufficient to establish biofeedback as an effective isolated treatment; it may have utility when combined with other modalities for behavioral/self‑regulation goals.

See González‑González and Florjanski reviews.

Jaw mobility mechanical stretching devices: Devices (eg, TheraBite, Jaw Dynasplint) are considered unproven due to limited, small, or low‑quality trials, adherence challenges, and inconclusive clinical impact.

See Lee et al. (2018), Kraaijenga et al. (2014) and policy review.

Epigenetic appliances: No quality evidence supports the efficacy of epigenetic appliances for TMJ disorders; effects on health outcomes cannot be established.

Literature review found insufficient evidence.

Conservative therapies should be tried and documented prior to injections or surgical interventions.
Minimally invasive options (arthrocentesis, arthroscopy, injections, trigger point injections) are preferred before arthroplasty or joint replacement.
Surgery is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe.

Prior Authorization

Prior Authorization for Major TMJ Surgery

Arthroplasty and total joint replacement are reserved for patients who have not responded to conservative and minimally invasive procedures. Prior authorization reviews will expect documentation demonstrating trial and failure of less invasive treatments, the severity of symptoms, and the clinical rationale for proceeding to major surgery.

Prior authorization is required for major TMJ surgeries (e.g., arthroplasty, joint replacement).
Operative indication must include documented failure of conservative and minimally invasive therapies and evidence of moderate to severe pain or dysfunction.
Clinical documentation should include pretreatment therapeutic goals and rationale for surgery.

Designed to reduce or eliminate clenching/bruxism and to keep or reposition the jaw in a more relaxed position to relieve myofascial pain and dysfunction.

TypesIncludes stabilization splints (hard night guards) and mandibular repositioning devices; materials and coverage vary by appliance.

Myofascial trigger point injection — procedure and intended effect

DefinitionMyofascial trigger point injection: targeted injection or dry needling of focal ‘knots’ in masticatory muscles to relax muscle fibers and remove metabolite waste, breaking the pain–tension cycle.

Agents/techniquesMay be performed as dry needling alone or followed by injections such as local anesthetic, corticosteroid, dextrose, saline, platelet‑rich plasma, or botulinum toxin‑A in some studies.

Intended effectAims to decrease localized muscle pain and increase MMO by reducing muscle hyperactivity and pain sensitization.

Jaw mobility devices — definition and policy note (unproven)

DefinitionJaw mobility devices: passive mechanical stretching systems used for prolonged mandibular hypomobility rehabilitation (examples: TheraBite, Jaw Dynasplint, OraStretch, Therapacer).

Intended useProvide sustained passive stretch to improve jaw opening in patients with limited range of motion after injury or surgery.

Policy positionConsidered unproven for TMJ disorders in this policy due to limited, small, or low‑quality trials and adherence concerns; clinical impact is not established.

Epigenetic appliances — definition and policy position (unproven)

DefinitionEpigenetic appliances: intraoral devices resembling orthodontic retainers that are worn (often overnight) to apply pressure purported to stimulate bone remodeling (osteoblast/osteoclast activity) and expand the jaws.

ClaimsPromoted for a variety of conditions including TMJ disorders, sleep apnea, and chronic headaches based on the premise of pressure‑induced skeletal change.

Policy positionThe policy considers epigenetic appliances unproven for TMJ disorders; a review found no quality evidence to support efficacy and effects on health outcomes cannot be established.

MMO — maximum mouth opening (outcome measure)

DefinitionMaximum mouth opening (MMO): the greatest interincisal distance a patient can achieve, used as an objective outcome measure to assess functional improvement after TMJ interventions.

Clinical useMMO is reported in trials of arthrocentesis, injections, splints, and physical therapy to evaluate change in jaw range of motion and treatment effect.

InterpretationImprovements in MMO have been demonstrated with arthrocentesis (often when followed by injection) and with some needling therapies, though evidence quality varies.

Myofascial (myogenic) TMD — definition

DefinitionMyofascial (myogenic) TMD: a subtype of temporomandibular disorder in which pain originates primarily from the masticatory muscles and their associated trigger points.

Clinical featuresCharacterized by focal muscle pain, tenderness to palpation, and reduced mouth opening; often related to acute or repeated microtrauma of muscle fibers.

Common treatments studiedInterventions studied for myofascial TMD include trigger point injections, dry needling, physical therapy, and occlusal splint therapy.

Conservative therapy — definition (conservative, reversible, evidence‑based modalities)

DefinitionConservative therapy: initial treatment using conservative, reversible, evidence‑based modalities such as education, self‑care, soft diet, NSAIDs, heat, jaw rest, physical therapy, and occlusal splints.

RationaleAADOCR and guidelines recommend beginning with conservative, reversible options because many TMDs improve or resolve over time and these modalities avoid irreversible harm.

Role in sequencingConservative therapy is the preferred initial approach and should be attempted before progressing to injections or surgical interventions unless specific indications justify earlier invasive care.

Surgical intervention indication — definition and constraints

DefinitionIndication for surgical intervention: surgical procedures (e.g., arthroplasty, total joint replacement, orthognathic surgery) reserved for patients with moderate to severe pain and/or dysfunction after nonsurgical and minimally invasive therapies have failed.

PrerequisitesSurgery is indicated only when conservative and minimally invasive therapies have been ineffective; not indicated for asymptomatic or minimally symptomatic patients, and goals must be individualized.

Documentation expectationMedical records should support prior attempts at conservative/minimally invasive care and demonstrate severity (pain/dysfunction) to justify surgical intervention; prior authorization may be required per InterQual criteria.

Removed CPT codes 21089 and 21499 from the applicable codes list.