ModifiedUnitedHealthcarePolicy CS195NE.I

Treatment of Temporomandibular Joint (TMJ) Disorders (for Nebraska Only)

This policy governs coverage and medical necessity for non‑surgical and surgical treatments of temporomandibular joint disorders for UnitedHealthcare members in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint (TMJ) Disorders (for Nebraska Only)

Policy CodePolicy CS195NE.I

Change TypeRevised device/appliance examplescontent and reference updates

Effective DateApr 1, 2025

Next Review Date

Key ActionDocument conservative therapy trials and clinical indications; prior authorization may be required for TMJ surgical procedures per plan rules.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary services to replace specific passive rehabilitation device examples with a broader term 'jaw mobility mechanical stretching devices' and updated examples of epigenetic appliances by adding 'Advanced Lightwire Functional (ALF) appliances'.

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

Removed reference link to the Medical Benefit Drug Policy titled Sodium Hyaluronate.

Updated related policy links to reflect current policy titles for Manipulation Under Anesthesia and for Prolotherapy and Platelet Rich Plasma Therapies (for Nebraska Only).

5Proven non-surgical services

36Network meta-analysis studies

E1700

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Example unproven HCPCS

Very low–moderateEvidence quality range

4Recent revision entries

Coverage Criteria for TMJ Disorders

Proven Non‑Surgical Treatments

Non-surgical services considered proven and medically necessary

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

These services are listed as proven and medically necessary for treating TMJ disorders per policy.

Surgical Treatments (subject to InterQual criteria)

Surgical services considered proven and medically necessary in certain circumstances

TMJ surgical procedures: Arthroscopy, Discectomy, Reconstruction, and Arthroplasty per InterQual clinical coverage criteria

Medical necessity for these procedures must meet InterQual CP or custom InterQual modules referenced in policy.

Unproven / Not Medically Necessary Services

Services identified as unproven and not medically necessary due to insufficient evidence

Unproven/not medically necessary therapies: Craniosacral manipulation/therapy; Jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System, Jaw Dynasplint System); Multiple occlusal splints (daytime+nighttime, maxillary+mandibular); Epigenetic appliances (Homeoblock, DNA Daytime/Nighttime appliance, Advanced Lightwire Functional (ALF) appliances)

These are explicitly listed as unproven and not medically necessary due to insufficient evidence of efficacy.

Coverage considerations by therapy

Summary of evidence-based coverage considerations

Conservative first-line: Initial management should use conservative, reversible, evidence-based modalities (education, occlusal splint therapy, physical therapy/exercise) as supported by guideline statements and trial evidence.

AADOCR and AAOMS guidance favor conservative reversible care first; documentation of conservative therapy is expected.

Minimally invasive options: Minimally invasive procedures (arthrocentesis with lavage ± injectables, intraarticular corticosteroid or hyaluronic acid injections, arthroscopy) have evidence of short- to intermediate-term pain and/or mouth opening benefits in some RCTs and meta-analyses, though evidence quality ranges from very low to moderate.

Arthrocentesis with lavage improves MMO and pain; corticosteroid injections may reduce pain with variable effects on MMO.

Needling and trigger point injections: Needling therapies (dry needling, local anesthetic, botulinum toxin A, platelet-rich plasma) show some short- and intermediate-term improvements in pain and MMO in low or very low quality evidence; conclusions are not definitive.

The policy identifies certain device-based and appliance therapies as unproven and not medically necessary for treatment of temporomandibular joint disorders. Specifically, the policy calls out jaw mobility devices (HCPCS codes E1700 and related E1701/E1702 entries) and epigenetic appliances among services considered unsupported by sufficient evidence and therefore subject to exclusion from coverage.

The policy notes that craniosacral manipulation/therapy and epigenetic appliances lack quality evidence demonstrating efficacy for TMJ disorders; the medical literature review did not identify sufficient evidence to establish an effect on health outcomes for these therapies.

Jaw mobility mechanical stretching devices (for example, TheraBite and Jaw Dynasplint) are considered unproven because published studies are limited by small sample sizes, short follow‑up, high loss‑to‑follow‑up, poor compliance, and inconclusive or unfavorable results; therefore evidence of efficacy and safety is insufficient to support coverage.

The policy revision replaces specific passive device listings with the broader term jaw mobility mechanical stretching devices (e.g., TheraBite Jaw Motion Rehabilitation System®, Jaw Dynasplint® System) and expands examples of epigenetic appliances (adding Advanced Lightwire Functional (ALF) appliances) in the list of services considered unproven and not medically necessary.

Summary of services identified as unproven or not medically necessary includes: craniosacral therapy, jaw mobility mechanical stretching devices (examples listed), multiple occlusal splints used concurrently (day/night or maxillary/mandibular), and epigenetic appliances (Homeoblock, DNA, ALF). These interventions are listed due to insufficient high‑quality evidence supporting clinical benefit.

Use of jaw mobility mechanical stretching devices for TMD is not supported by adequate evidence of efficacy and safety. Studies cited report low device adherence, limited participant numbers, and no significant advantage over conventional stretching or control measures; consequently coverage for these devices is not supported.

The policy language replaces the previous term for specific passive rehabilitation products with the broader descriptor jaw mobility mechanical stretching devices, reflecting an operational change to group device examples rather than listing only named products (e.g., TheraBite, Jaw Dynasplint).

Coding and Procedure Codes

Covered/Referenced 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.
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

Additional CPT CodesCPT

29804	Arthroscopy, temporomandibular joint, surgical.
97039	Unlisted modality (specify type and time if constant attendance).
97139	Unlisted therapeutic procedure (specify).

HCPCS/DME Codes (jaw mobility devices referenced)HCPCS

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, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for TMJ Surgical Procedures

Prior authorization is required for temporomandibular joint (TMJ) surgical procedures. Certain TMJ surgical services (for example, arthroscopy, discectomy, reconstruction, and arthroplasty) are considered medically necessary only in specific circumstances and clinical coverage criteria (such as InterQual) will be applied to determine medical necessity. Providers should submit documentation that demonstrates how the case meets applicable medical necessity criteria.

Refer to InterQual® CP: Procedures for Arthroscopy, Discectomy, Reconstruction and to InterQual® Client Defined CP: Arthroplasty (Custom) - UHG

Prior Authorization

Device Coverage and Prior Authorization

Prior authorization is suggested for certain devices related to TMJ care. Device types include TMJ prostheses (FDA Class III devices requiring PMA), continuous passive motion (CPM) machines (FDA Class II), and jaw motion/rehabilitation systems and accessories. FDA approval information is for reference and does not by itself determine coverage.

Examples of device HCPCS: E1700 (Jaw motion rehabilitation system), E1701 (replacement cushions), E1702 (replacement measuring scales)

Background on Temporomandibular Disorders

Temporomandibular disorders (TMD) encompass conditions affecting the TMJ and associated musculature that can cause pain, limited range of motion (reduced mouth opening), and joint noises. Many patients improve with conservative measures — such as activity modification, analgesics, physical therapy, and occlusal splint therapy — while some refractory cases may require injections or surgical intervention.

Definitions and Procedure Descriptions

inv-29: Arthrocentesis — lavage/aspiration and/or injection of the TMJ to relieve pain and improve mouth opening

DefinitionArthrocentesis: lavage/aspiration and/or injection of the temporomandibular joint to relieve pain and improve mouth opening.

Procedure detailMinimally invasive joint lavage that flushes the TMJ (commonly with Ringer's lactate or saline) to remove inflammatory debris and may be followed by intra‑articular injectables.

Clinical effectContributes to improving maximum mouth opening (MMO) and reducing TMJ pain; benefits observed short- to intermediate-term in RCTs and systematic reviews.

inv-30: Occlusal splint — intraoral appliance intended to reduce clenching/bruxism and reposition the jaw

DefinitionOcclusal splint: an intraoral appliance (stabilization or repositioning) intended to reduce clenching/bruxism and reposition the jaw.

Policy Summary

PayerUnitedHealthcare

PolicyTreatment of Temporomandibular Joint (TMJ) Disorders (for Nebraska Only)

Policy CodePolicy CS195NE.I

Change TypeRevised device/appliance examplescontent and reference updates

Effective DateApr 1, 2025

Next Review Date

Key ActionDocument conservative therapy trials and clinical indications; prior authorization may be required for TMJ surgical procedures per plan rules.

SourceLink

On This Page

Network meta-analyses suggest local anesthetic and dry needling improve MMO; PRP ranks high for short-term pain but overall evidence is low quality.

Occlusal splint therapy demonstrates short-term benefits for pain and mouth opening; specific types (HSS, SSS, ARS, mini-anterior) have varying evidence; multimodal therapy (counseling + HSS) may provide maximal improvement.

Network meta-analyses provide moderate to very low quality evidence supporting splint effectiveness; benefits may diminish long-term.

Interventions considered unproven or unsupported: Craniosacral manipulation, epigenetic appliances, and certain jaw mobility mechanical stretching devices lack sufficient high-quality evidence to establish efficacy and safety.

Studies are limited by small sample sizes, short follow-up, heterogeneity, and poor compliance.

TMJ prostheses product codes referenced at FDA (LZD, MPI)

Prior Authorization

Prior Authorization and Utilization Review

UnitedHealthcare may require prior authorization and will apply utilization review consistent with the member's federal, state, or contractual benefit plan. UnitedHealthcare may use third‑party clinical tools (e.g., InterQual®) to assist in assessing medical necessity.

Check and follow the member's federal, state, or contractual benefit plan terms; those terms govern in case of conflict
InterQual® criteria may be used during utilization review

Billing Rule

Coding and Coverage Reference — Denial Risk

Coding lists in this policy are provided for reference only and do not guarantee coverage or payment. Inclusion of a code does not imply that the service described by the code is a covered benefit. Providers should verify coverage and billing rules under the member's specific benefit plan.

Examples of referenced codes are included in the Applicable Codes section (e.g., 20605, 20606, 21010, 21243, 29800, 29804, E1700–E1702)
Listing of a code is not a determination of coverage or reimbursement

Denial Risk

Lack of Evidence May Trigger Denial

Therapies and devices lacking quality evidence of efficacy and safety may be considered not medically necessary and could be denied. Examples include craniosacral therapy, epigenetic appliances, and certain jaw mobility mechanical stretching devices where evidence is insufficient or compliance is poor.

Craniosacral manipulation/therapy: insufficient quality evidence
Epigenetic appliances: insufficient quality evidence
Jaw mobility mechanical stretching devices (e.g., Jaw Dynasplint, TheraBite®): limited or inconclusive evidence and compliance concerns

Note

Coverage Determination and Plan Terms

Coverage determinations must reference the member's federal, state, or contractual benefit plan; if plan terms differ from this policy, the federal, state, or contractual requirements govern. Providers should verify applicability of this policy for the specific member before rendering services.

When a conflict exists, the federal, state, or contractual benefit plan requirements take precedence
This policy is informational and does not replace plan‑specific benefit provisions

Documentation Required

Conservative Therapy Trial Documentation

Providers must document trials of conservative therapies prior to escalation to invasive interventions when clinically appropriate. Documentation should show the type, duration, and response to conservative, reversible treatments (e.g., NSAIDs, soft diet, moist heat, physical therapy, splint therapy, trigger point management) in accordance with guideline recommendations.

Record conservative treatments attempted, dates, objective findings, and response to therapy
AAOMS and AADOCR guidance recommend initial conservative, reversible, evidence‑based modalities and require documentation that nonsurgical therapies have been ineffective before surgery

Note

Conservative‑First Approach

Treatment approach should follow a conservative‑first principle: use the most conservative, reversible, evidence‑based therapies initially and escalate to injections or surgery only after conservative measures have failed and clinical criteria for surgery are met.

Conservative modalities include splints, physical therapy, medications, jaw rest, and other reversible interventions
Surgery is indicated only after nonsurgical therapy has been ineffective and symptoms are moderate to severe

Used to treat myofascial pain dysfunction and TMJ disorders by reducing/eliminating tooth clenching or grinding and maintaining the jaw in a more relaxed position.

Formats/materialsSplints include stabilization (night guards) or mandibular repositioning devices; made from various materials and may cover all or some teeth in an arch.

inv-31: Arthrocentesis (alternate) — minimally invasive joint lavage procedure to flush the TMJ

Procedure descriptionMinimally invasive joint lavage procedure that flushes the TMJ (commonly with Ringer's lactate or saline) to remove inflammatory cell and extracellular matrix debris.

Adjunctive useArthrocentesis is often followed by intra‑articular injectables (e.g., corticosteroids, hyaluronic acid) which may improve outcomes compared with lavage alone.

Evidence summarySystematic reviews report arthrocentesis improves MMO and pain over minimum follow-up of 6 months; evidence limited by heterogeneous protocols and follow-up durations.

inv-32: Occlusal splint types — lists HSS, SSS, ARS, mini-anterior splint, pre-orthodontic splint etc.

Included splint typesHard stabilization splint (HSS); Soft stabilization splint (SSS); Anterior repositioning splint (ARS); Mini‑anterior splint; Prefabricated splints and non‑occluding splints.

Comparative evidenceNetwork meta-analysis of RCTs (48 trials) evaluated HSS, SSS, ARS, mini‑anterior, prefabricated, non‑occluding splints and counseling combinations for pain and MMO outcomes.

Clinical findingModerate to very low quality evidence supports occlusal splint effectiveness; CT + HSS may provide maximal improvement depending on disorder type.