Subject: Intraoral Appliances for Headaches
Date: June 27, 2011
This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
Each benefits plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
PolicyAetna considers intraoral appliances (for example, the Nociceptive Trigeminal Inhibition-Tension Suppression System) experimental and investigational for the treatment of headaches because their effectiveness for this indication has not been established.
BackgroundHeadache is a common medical complaint and is generally categorized by one of three syndromes:
Migraine is characterized by attacks of headache, nausea, vomiting, photophobia, phonophobia and malaise. Tension-type headache is mild to moderate in intensity, bilateral, and non-throbbing without other associated features. Cluster headache is strictly unilateral, begins quickly without warning, and reaches maximal intensity within a few minutes. It is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing.
Other headache syndromes may include sinus headache, post-traumatic headache, medication over-use and temporomandibular joint (TMJ) dysfunction. The typical headache associated with TMJ presents as unilateral ear or pre-auricular pain that radiates to the jaw, temple or neck. The pain is deep, dull, continuous and usually worse in the morning. It is typically associated with a limitation of jaw motion and deviation of the jaw upon opening. Physical examination may reveal tenderness of the muscles of mastication and less commonly, clicking of the joint. Many cases are difficult to distinguish from tension-type headaches (Bajwa and Sabahat, 2008).
Pharmacological treatment of headaches is aimed at reversing, aborting, or reducing pain and the accompanying symptoms of an attack as well as optimizing the patient's ability to function normally.
Most attacks of mild migraine can be effectively treated by anti-emetics followed by analgesics such as aspirin, acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). Moderate to severe attacks are successfully treated using combinations of ergotamine tartrate, dihydroergotamine and triptans with anti-emetics, simple analgesics, NSAIDs and/or opiates.
For severe migraine headaches, alternative medications include intravenous administration of neuroleptics such as chlorpromazine (Thorazine) and prochlorperazine (Compazine); occasionally corticosteroids such as prednisone, hydrocortisone, dexamethasone and methylprednisone, and lastly parenteral narcotic analgesics such as meperidine and the nasal spray butorphanol tartrate (Stadol NS).
The acute or abortive therapy of tension-type headache (TTH) ranges from non-pharmacologic therapies to analgesic medications. The treatment of headache due to TMJ primarily involves therapy of the joint disorder itself. Most cases can be treated with local heat, physical therapy, dental hygiene, NSAIDs and dietary measures (Bajwa and Sabahat, 2008).Complementary and alternative therapies for headaches include acupuncture, aromatherapy, biofeedback, Bowen technique (remedial therapy tool to manage pain), chiropractic, cranial electrical stimulation, hyperbaric oxygen therapy, hypnotherapy, massage, nutrition, reflexology, Reiki, spinal/osteopathic manipulation, transcranial magnetic stimulation and yoga, although the effectiveness of many of these approaches has not been established. Recently, it has been suggested that intraoral dental appliances used to reduce the intensity and the amount of jaw muscle activity may be beneficial in preventing headaches.
One design covered the maxillary occlusal surfaces of the dentition while the other design contacted the palatal mucosa only and was free of the occlusion. Treatment outcome was expressed as the number of migraine attacks per week per patient.
The occlusal cover appliance reduced the number of attacks on average to about 40% of those normally experienced. The improvement was most marked in those who had frequent migraine attacks (that is, 2 attacks per week on a regular basis). The authors concluded that acrylic appliance therapy is of value in migraine sufferers who have attacks on waking but the appliance design has to involve covering of the occlusal surfaces of all of the teeth (note: the NTI-tss only covers the front 2 teeth). The drawbacks of this study were that it was a non-randomized study with a small sample size and no long-term follow-up.Two studies comparing the NTI-tss splint with a standard stabilization splint in the treatment of TMJ have been published (Magnusson, et al., 2004; Jokstad, et al., 2005). Results obtained by Magnusson favored the use of a stabilization splint over the NTI splint. In addition, one subject treated with the NTI-tss splint exhibited an impaired occlusion at the 6-month follow-up. Jokstad found no differences between a standard stabilization splint versus the NTI splint regarding TMJ treatment efficacy over a 3-month period. Both comparative studies were small and neither focused on migraine as an outcome measure. Further studies are needed to determine the effects of the NTI-tss splint on the treatment of headaches, including migraine, as well as possible long-term side effects.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes not covered for indications listed in the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation: includes removal|
|HCPCS codes not covered for indications listed in the CPB:|
|D7880||Occlusal orthotic device, by report|
|D8210||Removable appliance therapy|
|D9940||Occlusal guard, by report|
|ICD-9 codes not covered for indications listed in the CPB:|
|339.00 - 339.89||Other headache syndromes|
|346.00 - 346.91||Migraine|
|349.0||Reaction to spinal or lumbar puncture [headache]|
The above policy is based on the following references:
Revision DatesOriginal policy: November 4, 2004
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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