ModifiedUnitedHealthcarePolicy CSNCT0079.07

Treatment of Temporomandibular Joint Disorders (TMJ/TMD) — North Carolina

Medical policy governing coverage and clinical guidance for non‑surgical and surgical treatments of temporomandibular joint disorders for North Carolina Medicaid members and providers.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (TMJ/TMD) — North Carolina

Policy CodePolicy CSNCT0079.07

Change TypeClarified device terminologyupdated examples and related links

Effective DateApr 1, 2025

Next Review Date

Key ActionRefer to InterQual criteria and document prior conservative management when seeking prior authorization for TMJ surgical procedures.

SourceLink

POLICY UPDATE CHANGES

Replaced 'passive rehabilitation therapy devices (e.g., TheraBite Jaw Motion Rehabilitation System ® ) and low-load prolonged-duration stretch devices (e.g., Jaw Dynasplint ® System)' 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 related policy links and reference to Manipulation Under Anesthesia (for North Carolina Only).

NCstate applicability

5non-surgical proven services

36RCTs (arthrogenous TMD)

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RCTs (needling meta-analysis)

CSNCT0079.07policy identifier

Coverage Criteria for TMJ/TMD Treatments

Non-surgical proven medically necessary

Covered when supported by medical necessity and/or InterQual criteria:

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

Listed as proven and medically necessary for treating TMJ disorders.

Surgical procedures with InterQual-based criteria

Surgical services proven and medically necessary in certain circumstances when InterQual criteria are met:

Procedures with InterQual criteria: Arthroscopy, Discectomy, Reconstruction, Arthroplasty (see InterQual CP and InterQual Client Defined CP for specific criteria)

Refer to InterQual for specific clinical coverage criteria and authorization; these procedures are considered proven and medically necessary in certain circumstances.

Unproven and not medically necessary

Explicitly listed as unproven / not medically necessary due to insufficient evidence of efficacy:

Unproven procedures/devices: Biofeedback; Craniosacral manipulation/therapy; Jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint); Multiple occlusal splints (daytime/nighttime or maxillary/mandibular combinations); Epigenetic appliances (e.g., Homeoblock, DNA, Advanced Lightwire Functional [ALF])

These are stated as unproven and not medically necessary in the policy due to limited or low-quality evidence and are not supported for routine coverage.

Coverage stance and rationale

Summary of evidence-based coverage stance for non-surgical TMD therapies

Conservative-first principle: Initial management of TMD should use conservative, reversible, evidence-based modalities (occlusal splints, physical therapy, education, counseling, exercise) because many TMDs improve over time and these carry lower risk.

Supported by AADOCR guidance and multiple trials showing many conservative modalities provide symptomatic relief with lower risk of irreversible harm.

Minimally invasive treatments supported by evidence: Minimally invasive procedures (arthrocentesis with lavage; intra-articular injections of corticosteroids, hyaluronic acid, or PRP; arthroscopy) demonstrate short- and intermediate-term benefit for pain and/or maximal mouth opening versus conservative or placebo in several systematic reviews and network meta-analyses, though evidence quality is often low to moderate and heterogeneity limits definitive conclusions.

Arthrocentesis contributes to improving MMO and pain when followed by injectables; network meta-analyses show CS/HA/injections often outperform control in short/intermediate term.

Trigger-point and needling therapies: Needling therapies (dry needling, local anesthetic injections, PRP, botulinum toxin) can improve pain and maximal mouth opening in myofascial TMD in the short and intermediate term, but evidence quality is low and no definitive superiority among needling types or substances was established.

Codes and durable medical equipment entries marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Examples in this policy that carry the asterisk include 90901, 97039, 97139, E0746, E1399, E1700–E1702, 21085, and 21499; providers should verify coverage and reimbursement under the applicable North Carolina Medicaid benefit terms before billing.

Jaw mobility mechanical stretching devices (for example, TheraBite and Jaw Dynasplint) and other listed services are classified as unproven and not medically necessary because available studies are limited by small sample size, short follow-up, high loss-to-follow-up, poor compliance, and inconclusive or unfavorable results. The policy therefore excludes these devices from proven therapies for TMJ disorders in the absence of higher-quality evidence.

The policy revision effective 04/01/2025 clarified terminology by replacing prior wording with the grouped term jaw mobility mechanical stretching devices and explicitly cited examples (e.g., TheraBite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System) to standardize the list of unproven devices in the policy.

The following therapies are listed in this policy as unproven and not medically necessary for treating TMJ disorders due to insufficient evidence: biofeedback; craniosacral manipulation/therapy; jaw mobility mechanical stretching devices (e.g., TheraBite, Jaw Dynasplint); multiple occlusal splints (daytime and nighttime, maxillary and mandibular used concurrently); and epigenetic appliances (e.g., Homeoblock™, DNA®, Advanced Lightwire Functional [ALF] appliances).

Review of the medical literature did not identify quality evidence to support the efficacy of craniosacral manipulation/therapy or epigenetic appliances for treatment of TMJ disorders. As a result, their effect on health outcomes cannot be established and they are listed as unproven in this policy.

Policy history documents that the 04/01/2025 revision updated the list of unproven and not medically necessary services to explicitly include jaw mobility mechanical stretching devices among examples and to revise the examples of epigenetic appliances (adding ALF). These changes clarify the device grouping and example list used in the policy.

Coding and Billing for TMJ/TMD Services

Surgical and invasive procedure CPT codesCPT

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 19

1/2

Unlisted/Device and biofeedback codes (some not on NC Medicaid fee schedule)mixedNot Covered

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 referencedmixed

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

Provider Actions and Authorization Guidance

Note

Coverage decision context

Coverage determinations are made in the context of the member's federal, state, and contractual benefit terms. This policy provides general guidance but does not replace the specific benefit language in the member's plan. In the event of a conflict, the applicable federal, state, or contractual requirements for benefit plan coverage govern.

Reference federal, state, and contractual benefit terms when determining coverage.
Policy guidance, InterQual criteria, and FDA information are informational and must be applied alongside applicable benefit terms.

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain TMJ surgical procedures and some device- or facility-related services. Providers should verify plan-specific prior authorization requirements before scheduling services.

Use InterQual criteria for arthroscopy, discectomy, reconstruction, and arthroplasty as applicable.
Coding lists in this policy are for reference only and do not constitute authorization; submit prior authorization requests with supporting clinical documentation.

Background and Evidence Summary

Temporomandibular disorders (TMD) are a heterogeneous group of conditions affecting the temporomandibular joint and surrounding masticatory musculature, commonly presenting with pain, limited mouth opening, and joint noises. Many TMDs improve with conservative, reversible therapies—such as education, soft diet, jaw rest, analgesics/NSAIDs, physical therapy, occlusal splint therapy, and trigger point injections—while refractory or severe cases may require minimally invasive procedures or, in select circumstances, surgery after conservative management has failed.

Definitions and Key Terms

inv-27: Occlusal splints — definition and purpose

TermOcclusal splints

DefinitionStabilization (night guards) or mandibular repositioning devices intended to reduce or eliminate clenching/bruxism and to keep or reposition the jaw in a more relaxed position; made of various materials and covering all or part of a dental arch.

Purpose/UseUsed to treat myofascial pain dysfunction and temporomandibular disorders to reduce pain and improve mouth opening, often as part of multimodal conservative therapy.

Evidence noteNetwork meta-analysis of 48 RCTs found moderate to very low‑quality evidence supporting short-term pain reduction and improved mouth opening; multimodal therapy (counseling + hard stabilization splint) may provide maximum benefit.

inv-28: Myofascial trigger points — definition and treatment modalities

Policy Revision History

2025-11-01related_policies_link_updateLatest

Updated related policy reference link for Manipulation Under Anesthesia (for North Carolina Only).

2025-10-01related_policies_link_update

Updated related policy reference link to reflect the current policy title (related policy links updated).

2025-04-01coverage_revision

Revised list of unproven and not medically necessary services: replaced language for passive rehabilitation/low-load stretch devices with 'jaw mobility mechanical stretching devices' (e.g., TheraBite, Jaw Dynasplint) and added Advanced Lightwire Functional (ALF) appliances to examples of epigenetic appliances; updated related coverage rationale for prolotherapy and PRP therapies.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint Disorders (TMJ/TMD) — North Carolina

Policy CodePolicy CSNCT0079.07

Change TypeClarified device terminologyupdated examples and related links

Effective DateApr 1, 2025

Next Review Date

Key ActionRefer to InterQual criteria and document prior conservative management when seeking prior authorization for TMJ surgical procedures.

SourceLink

On This Page

Network meta-analysis included 21 RCTs (959 participants) with low or very low quality evidence.

Physical therapy and manual therapy: Physical therapy (including craniomandibular manual therapy and exercise programs) added to occlusal splint and education can improve pain and function versus splint/education alone in some RCTs; benefits may decrease over time without ongoing exercise.

RCTs and systematic reviews report mid-term improvements; effects may wane over longer follow up.

Occlusal splints: Occlusal splint therapy has evidence (moderate to very low quality across studies) supporting short-term pain reduction and improved mouth opening; multimodal therapy (counseling plus hard stabilization splint) may yield maximal benefit.

Network meta-analysis of 48 RCTs demonstrates variable quality evidence with some benefit especially when combined with counseling.

Biofeedback and psychological interventions: Biofeedback and biofeedback-based cognitive behavioral approaches may reduce masticatory muscle activity and aid pain coping, but overall study quality is limited and evidence is insufficient to firmly establish efficacy for routine coverage.

Systematic reviews identify low-quality studies with small samples and heterogenous interventions.

Jaw mobility devices and epigenetic/craniosacral therapies: Jaw mobility mechanical stretching devices, epigenetic appliances, and craniosacral manipulation lack sufficient high-quality evidence for efficacy; compliance issues and small or heterogeneous studies limit support for coverage as proven therapies.

Feasibility trials and RCTs show limited or inconclusive benefit and poor compliance in many studies.

Surgical criteria: Surgery (including arthroscopy or open joint procedures) is indicated only after nonsurgical therapy has been ineffective and when pain and/or dysfunction are moderate to severe; not indicated for asymptomatic or minimally symptomatic patients.

AAOMS Parameters of Care specify surgery only after failure of nonsurgical therapy and for moderate-to-severe symptoms; pretreatment goals should be individualized.

Device regulatory status (FDA) is informational; FDA approval alone is not a basis for coverage.

Step Therapy

Conservative-first treatment approach

Documented failure of conservative and minimally invasive therapies is required prior to elective TMJ surgery for internal derangement and many other surgical indications. Conservative-first approaches (e.g., splint therapy, physical therapy, medications, trigger point injections, arthrocentesis) should be attempted and clearly documented in the medical record.

Document trials of conservative care (type, dates, responses) and any minimally invasive procedures (e.g., arthrocentesis, intra-articular injections) prior to surgical authorization requests.
Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and symptoms are moderate to severe.

Documentation Required

Documentation and benefit determination requirements

Adequate clinical documentation is required to support benefit and medical necessity determinations. Include diagnostic findings, prior treatments and responses, objective measures of dysfunction or pain, and the rationale for the requested procedure or device.

Attach relevant clinical notes, imaging, operative reports, and documentation of conservative therapies when submitting prior authorization.
Coding inclusion in this policy does not guarantee coverage or payment; adjudication depends on documented medical necessity and plan terms.

Note

FDA device information (informational only)

FDA device classification and approvals are provided for informational purposes only and do not alone determine coverage.

TMJ prostheses are regulated by the FDA as Class III (PMA).
CPM machines are Class II devices. Providers should include clinical justification for device use beyond regulatory status.

Billing Rule

Coding inclusion is not authorization

Coding lists in this policy are provided for reference and do not constitute prior authorization or guarantee payment. Confirm coverage and billing requirements with the member's plan.

Include codes from the Applicable Codes lists when preparing authorization requests, but recognize that listing is informational only.
Verify proper CPT/HCPCS/ICD-10 coding and any modifier requirements with the payer.

Myofascial trigger points

DefinitionFocal knots in a band of skeletal muscle caused by acute or repeated microtrauma, common in TMJ disorders; produce localized muscle pain and dysfunction.

Typical treatmentsDry needling or wet needling (local anesthetic, botulinum toxin-A, PRP, saline), trigger point injections; injections relax muscle fibers, promote lengthening, and disrupt the pain–tension cycle.

Evidence noteNetwork meta-analysis of 21 RCTs (959 participants) showed improvements in pain and maximal mouth opening with needling therapies, but overall evidence quality was low to very low and no definitive superiority among needling types was established.

inv-29: Craniosacral manipulation/therapy — definition and characterization

TermCraniosacral manipulation/therapy

DefinitionA complementary health approach (also called craniosacral therapy) asserting that palpation and selective manual pressures on the cranium influence rhythmic cranial bone movement and cerebrospinal fluid or arterial pressure to achieve therapeutic effects.

Treatment characteristicsInvolves light-touch palpation and manual manipulation of cranial and sacral regions; proposed for a wide variety of conditions including TMJ but not standardized across providers.

Policy/evidence noteReview of the medical literature did not identify quality evidence supporting efficacy for TMJ disorders; listed as unproven and not medically necessary in this policy.

inv-30: Arthrogenous TMD — definition and evidence context

TermArthrogenous TMD

DefinitionTemporomandibular disorders originating from joint structures (intra‑articular pathology) affecting pain and maximal mouth opening (MMO).

Evidence contextNetwork meta-analyses (e.g., Al‑Moraissi 2020a) of multiple RCTs (36 studies for pain, 33 for MMO) compared arthrogenous TMD treatments and found minimally invasive procedures (arthrocentesis, intra‑articular corticosteroids or hyaluronic acid, arthroscopy) more effective than conservative care for short‑ and intermediate‑term pain and MMO improvements, though evidence quality was low to very low.

inv-31: Myofascial (myogenic) TMD — definition and typical management

TermMyofascial (myogenic) TMD

DefinitionTMD related primarily to masticatory muscle pain and dysfunction rather than intra‑articular joint pathology.

Typical managementManaged with conservative measures (education, exercises, physical therapy), needling therapies (dry needling or injections with local anesthetic, botulinum toxin, PRP), and adjunctive modalities as indicated.

Evidence noteNetwork meta-analysis of needling therapies showed short‑ and intermediate‑term improvements in pain and MMO for myofascial TMD, but the overall evidence quality was low and results do not establish a clear superior needling method.

inv-32: TMJ prostheses — FDA Class III devices

TermTMJ prostheses

Regulatory classificationDevices regulated by the U.S. Food and Drug Administration as Class III devices requiring premarket approval (PMA).

Reference guidanceComplete list of approved products may be found via FDA PMA database using product codes LZD and MPI (informational only).

inv-33: Continuous passive motion (CPM) machines — FDA Class II

TermContinuous passive motion (CPM) machines

Regulatory classificationClass II device per the U.S. Food and Drug Administration (product code BXB).