Intra-oral Appliances for Headaches and Trigeminal Neuralgia

Aetna excludes intra-oral appliances (e.g., NTI‑TSS) for treatment of headaches and trigeminal neuralgia as experimental/investigational and not covered, including listed CPT (e.g., 21110), HCPCS/dental codes (e.g., D7880, D9940, E0486, etc.) and ICD‑10 headache/TN codes (e.g., G43.*, G44.*, G50.0, R51). The key requirement/justification is that effectiveness has not been established for these indications, and the policy scope is limited to headaches/TN (TMJ appliances are addressed under a separate policy).

"Specific CPT/HCPCS codes listed by the policy are not covered for the indications listed in the CPB: CPT 21110 (application of interdental fixation device for conditions other than fracture or disl..."

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