ModifiedUnitedHealthcarePolicy CS195IN.06

Treatment of Temporomandibular Joint Disorders (for Indiana Only)

Policy governing clinical coverage and evidence-based determinations for treatments of temporomandibular joint disorders for UnitedHealthcare members in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for Indiana Only)

Policy CodePolicy CS195IN.06

Change TypeRevised coverage list; documentation clarifications; code removals

Effective DateJun 1, 2026

Next Review Date

Key ActionEnsure medical records fully document history, exam, and relevant test results to support medical necessity for requested TMJ services.

SourceLink

POLICY UPDATE CHANGES

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

Added language clarifying medical records documentation expectations to support medical necessity determinations.

Removed CPT codes 21089 and 21499 from applicable codes.

Updated Description of Services and Clinical Evidence sections to reflect most current information and archived previous policy version CS348IN.05.

Indiana-onlystate applicability

4+unproven services listed

Multiplecodes provided

2023-03FDA safety note date

06/01/2026last revision

Coverage Criteria for TMJ Treatments

Unproven / Not Medically Necessary Services

The following services are considered unproven and not medically necessary for treating temporomandibular joint (TMJ) disorders due to insufficient evidence of efficacy:

Unproven / Not Medically Necessary Services: Biofeedback; Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System); Multiple occlusal splints used concurrently (e.g., daytime and nighttime splints, maxillary and mandibular splints); Epigenetic appliances (e.g., Homeoblock, DNA (Daytime/Nighttime appliance), Advanced Lightwire Functional (ALF) appliances)

This list is not all-inclusive; these services are considered unproven due to insufficient evidence of efficacy as stated in the policy.

The policy identifies the following services as unproven and not medically necessary for treating temporomandibular joint (TMJ) disorders due to insufficient evidence of efficacy: biofeedback; jaw mobility mechanical stretching devices (for example, TheraBite and Jaw Dynasplint systems); multiple occlusal splints used concurrently (for example, daytime and nighttime, or maxillary and mandibular splints); and epigenetic appliances (for example, Homeoblock, DNA daytime/nighttime appliances, and Advanced Lightwire Functional [ALF] appliances).

Effective 06/01/2026, the policy's list of services considered unproven and not medically necessary was revised. The revision removed craniosacral manipulation/therapy from the previously listed unproven therapies; the remaining unproven services continue to include biofeedback, jaw mobility mechanical stretching devices, multiple occlusal splints used concurrently, and epigenetic appliances.

Additional descriptive examples called out in the policy include biofeedback; specific jaw mobility mechanical stretching devices such as the TheraBite Jaw Motion Rehabilitation System and the Jaw Dynasplint System; and use of multiple occlusal splints concurrently (for example, daytime and nighttime splints or maxillary and mandibular splints). These items are cited as unproven because current evidence does not establish their efficacy for TMJ disorders.

Note: the policy was revised on 06/01/2026 to update the list of services classified as unproven or not medically necessary; the revision specifically removed craniosacral manipulation/therapy from that list and also updated medical records documentation expectations used in reviews.

Relevant Procedure and Supply Codes

Procedure CPT codes (reference)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

Biofeedback / DME / jaw devices (HCPCS)HCPCS

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 and policy code changesmixed

LZD	FDA product code referenced for TMJ prostheses (use PMA search).
MPI	FDA product code referenced for TMJ prostheses (use PMA search).
BXB	FDA product code for continuous passive motion machines.
21089	CPT code removed from applicable codes per policy history.
21499	CPT code removed from applicable codes per policy history.

Provider Responsibilities and Documentation

Prior Authorization

Prior authorization note for Indiana

Codes marked with an asterisk (*) in the Applicable Codes list are not managed for medical necessity review for the state of Indiana as of the policy effective date. Prior authorization and management requirements can change; providers must check the most up-to-date Indiana prior authorization list at Prior Authorization and Notification: UnitedHealthcare Community Plan of Indiana before submitting requests.

Affected codes include but are not limited to: *90901, *E0746, *E1399, *E1700, *E1701, *E1702.

Note

Verify plan and contractual requirements

Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws. Before using this policy, verify the member’s plan and any federal, state, or contractual benefit requirements that may affect coverage. Coverage determinations must reference those governing requirements when they differ from this policy.

Background on Temporomandibular Disorders

Temporomandibular disorders (TMJ disorders) are a heterogeneous group of conditions affecting the temporomandibular joint and surrounding musculature. They commonly present with jaw pain, limited range of motion, and joint noises. Initial management typically emphasizes conservative, reversible measures (for example, anti-inflammatory medications, soft diet, jaw rest, heat, physical therapy, occlusal splints, and medication management); escalation to injections or surgery is considered when conservative care fails to control symptoms or restore function.

Key Definitions and Device Classifications

inv-18: Arthrocentesis — definition and clinical intent

DefinitionArthrocentesis (lavage): a minimally invasive procedure in which irrigants are injected into the temporomandibular joint space to remove inflammatory mediators or increase mobility by removing intra-articular adhesions.

Clinical intentReduce intra-articular inflammation and improve joint mobility by lavage of mediators and disruption/removal of adhesions.

Typical role in care pathwayConsidered after failure of conservative, reversible treatments (e.g., NSAIDs, soft diet, jaw rest, physical therapy) and before more invasive surgery, when indicated by persistent pain or restricted range of motion.

inv-19: Occlusal splints — definition and types (stabilization vs repositioning) and intended effects

DefinitionOcclusal splints: intraoral appliances fabricated to cover some or all teeth of an arch to reduce clenching/bruxism and to maintain or reposition the jaw in a more relaxed position.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (for Indiana Only)

Policy CodePolicy CS195IN.06

Change TypeRevised coverage list; documentation clarifications; code removals

Effective DateJun 1, 2026

Next Review Date

Key ActionEnsure medical records fully document history, exam, and relevant test results to support medical necessity for requested TMJ services.

SourceLink

On This Page

Documentation Required

Required medical record documentation

The patient’s medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation should be legible, maintained in the patient’s medical record, and made available upon request.

Examples of required elements: relevant medical history, findings from the physical examination, results of pertinent diagnostic tests or procedures, and documentation of conservative therapies attempted and patient response.
Lack of adequate documentation may result in denial or inability to assess coverage.

Denial Risk

Documentation-related denial risk

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested. The patient’s medical record must fully support medical necessity; if the documentation does not, the claim may be denied.

Documentation should include: history, physical exam, diagnostic test results, and documentation of conservative therapy where applicable.
Insufficient or missing documentation creates a risk of denial or inability to determine coverage.

Documentation Required

Medical records requirements

Benefit coverage is governed by federal, state, or contractual requirements; documentation supporting medical necessity should be maintained and made available upon request. Verify plan-specific requirements before submission.

TypesStabilization splint (night guard/occlusal guard) and mandibular repositioning splint/device.

Intended effectsReduce or eliminate clenching or tooth grinding, protect dentition, and alter mandibular position to alleviate myofascial pain and TMJ symptoms.

inv-20: Myofascial trigger points — definition and common treatments (dry needling, injections)

DefinitionMyofascial trigger points: focal knots in a band of skeletal muscle caused by acute or repeated microtrauma, commonly seen with TMJ disorders and associated with localized pain and muscle tightness.

Common treatmentsDry needling to mechanically disrupt trigger points, or injections (e.g., corticosteroid, dextrose, or saline) to relax muscle fibers and remove metabolite waste.

Therapeutic goalBreak the pain–tension cycle by lengthening muscle fibers and reducing local nociception to improve function and decrease pain.

inv-21: TMJ prostheses (regulatory) — note that TMJ prostheses are FDA Class III devices requiring PMA, product codes LZD and MPI referenced

FDA classificationTemporomandibular joint prostheses are regulated by the FDA as Class III devices requiring premarket approval (PMA).

Product codes referencedProduct codes LZD and MPI are cited for searching FDA PMA listings of approved TMJ prostheses.

Guidance for completenessRefer to FDA PMA database for a complete list of approved TMJ prosthetic products (use product codes LZD and MPI).

inv-22: Continuous passive motion machines — classification as FDA Class II devices (product code BXB)

FDA classificationContinuous passive motion machines are approved by the FDA as Class II devices.

Product codeFDA product code BXB is used for continuous passive motion machines and related FDA information.

Regulatory noteClass II devices meet General Control requirements and Performance Standards; consult the FDA PMN database (product code BXB) for additional details.