E1701, Replacement cushions for jaw motion rehabilitation system, pkg. of 6
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The policy does not provide a discrete 'Documentation Requirements' section; however, HCPCS codes and ICD-10 codes are listed as "covered if selection criteria are met," implying documentation must demonstrate that selection criteria are met.
- Clinical documentation should support the covered indication: mandibular hypomobility caused by radiation in persons with head and neck cancers (for example, diagnosis codes such as C76.0 and Z92.3 and clinical evidence of mandibular hypomobility).
- Because some plans exclude coverage as over-the-counter equipment, documentation of medical necessity and that the device is prescribed may be required per plan benefit descriptions.
- When making benefit coverage determinations based on this policy, reviewers must review the member's benefit contract or Summary Plan Description (SPD) for coverage, exclusions, and limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- Covered indications: TMJ disorders may be treated with nonsurgical services including arthrocentesis; intra-articular corticosteroid injections; trigger point injections; physical therapy; and occlusal splints (stabilization and repositioning).
- ICD-10: Z92.3 — Personal history of irradiation (covered if selection criteria are met).
- HCPCS: E1700 — Jaw motion rehabilitation system (covered if selection criteria are met).
- HCPCS: E1701 — Replacement cushions for jaw motion rehabilitation system, package of six (covered if selection criteria are met).
- HCPCS: E1702 — Replacement measuring scales for jaw motion rehabilitation system, package of 200 (covered if selection criteria are met).
- Aetna considers jaw motion rehabilitation system (e.g., the Therabite Jaw Motion Rehabilitation System, and the OraStretch press) medically necessary to treat mandibular hypomobility caused by radiation in persons with head and neck cancers.
9 Active Policies
ANTHEM-GL-A051149, CPT
UHC-POL-temporomandibular-joint-disorders, Treatment of Temporomandibular Joint Disorders
AETNA-CPB-0412, Jaw Motion Rehabilitation Systems
BCBSIL-SUR705.010, Temporomandibular Joint Disorders
BCBSMT-SUR705.010, Temporomandibular Joint Disorders
Related Codes
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