Clinical Policy Bulletin: Therabite Jaw Motion Rehabilitation System
Aetna considers the Therabite Jaw Motion Rehabilitation System medically necessary to treat mandibular hypomobility caused by radiation in persons with head and neck cancers.
Aetna considers the Therabite Jaw Motion Rehabilitation System experimental and investigational for all other indications because of insufficient evidence in the peer-reviewed literature, including any of the following conditions:
Most head and neck cancers are treated with surgery, radiation, or a combination of the 2 modalities. The choice of treatment depends primarily on the anatomic site, extent and histologic grading of the tumor, and the presence of infection. Modern reconstructive techniques permit cancer patients, especially those with head and neck malignancies, to undergo more immediate reconstruction and thereby achieve better functional outcomes while still progressing through multimodality treatment in a timely manner. However, the more aggressive the cancer therapy, the more it places patients at risk for oral complications related to treatment.
One of the major complications from therapeutic administration of ionizing radiation to the head and neck is mandibular hypomobility -- a reduction in mandibular range of motion (ROM) caused by radiation-induced scarring and contraction of soft tissues surrounding the jaw. Clinically, the severity of mandibular hypomobility is related to the radiation dose, volume of tissue treated, and age of the patient.
Mandibular hypomobility is treated by stretching the scar tissue. Methods commonly used to stretch the scar tissue and increase mandibular ROM include: (i) oral opening exercises; (ii) stacking tongue blades between the molars; (iii) continuous passive motion of the jaw; and/or (iv) stretching the jaw using custom-made mechanical devices. One such custom-made device is the Therabite, a threaded screw-type instrument that is placed between the teeth and turned to gradually open the jaw, much like a car jack. Preliminary evidence indicates that the Therabite is more effective than other modalities in maintaining and/or improving mandibular ROM in irradiated patients. There are, however, inadequate outcomes data comparing the Therabite to more conventional methods to support the use of Therabite for any other condition.
Melchers and associates (2009) examined the factors that may influence Therabite exercise adherence, how these interrelate and provided aims for interventions to increase adherence. These researchers performed a multi-center, formal-evaluative qualitative retrospective study. A total of 21 patients treated for head-neck cancer were interviewed in semi-structured, in-depth interviews. Internal motivation to exercise, the perceived effect, self-discipline and having a clear exercise goal influenced Therabite exercise adherence positively. Perceiving no effect, limitation in Therabite opening range and reaching the exercise goal or a plateau in mouth opening were negative influences. Pain, anxiety and physiotherapists could influence adherence both positively and negatively. Based on the results, a model for Therabite exercise adherence was proposed. It is important to signal and evaluate the factors that negatively influencing Therabite adherence, especially before there is a perceived effect. The authors stated that research is needed to examine why some patients do not achieve results despite high exercise adherence, to identify effective exercise regimens and to assess proposed interventions aimed to increase Therabite exercise adherence.
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
HCPCS codes covered if selection criteria are met:
Jaw motion rehabilitation system
Replacement cushions for jaw motion rehabilitation system, package of six
Replacement measuring scales for jaw motion rehabilitation system, package of 200
ICD-9 codes covered if selection criteria are met:
Late effect of radiation
Effects of radiation, unspecified
ICD-9 codes not covered for indications listed in the CPB: (not all-inclusive):
430 - 438.9
Mandibular hyperplasia [coronoid]
524.60 - 524.69
Temporomandibular joint disorders
Anomalies of skull and face bones [Treacher Collins Syndrome]
Abnormal involuntary movements [trismus]
800.00 - 804.99
Fractures of skull
830.0 - 830.1
Dislocation of jaw
848.0 - 848.1
Sprain and strain of septal cartilage of nose and jaw
Intracranial injury, excluding those with skull fractures
870.0 - 873.9
Open wounds of head
Other specified blood vessels of head
Late effect of burn of eye, face, head, and neck
910.0 - 910.9
Superficial injury of face, neck and scalp except eye
918.0 - 918.9
Superficial injury of eye and adnexa
920 - 921.9
Contusions of face, scalp, neck, eyes and adnexa
Crushing injury of face, scalp and neck
941.00 - 941.5
Burn of head, face, and neck
950.0 - 951.9
Injury to optic nerve and pathways and other cranial nerves
959.01 - 959.09
Other and unspecified injury to head, face and neck
Other ICD-9 codes related to the CPB:
Malignant neoplasm of lip, oral cavity, and pharynx
150.0 - 150.9
Malignant neoplasm of esophagus
160.0 - 162.0
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses, larynx, and trachea
Malignant neoplasm of bones of skull and face, except mandible
Malignant neoplasm of mandible
Other and unspecified diseases of the oral soft tissues
Other symptoms involving head and neck
Personal history of irradiation
V10.01 - V10.03
Personal history of malignant neoplasm of tongue, other and unspecified oral cavity and pharynx, or esophagus
Personal history of malignant neoplasm of trachea
Personal history of malignant neoplasm of larynx
Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
Other postprocedural status
The above policy is based on the following references:
Kouyoumdjian JH, Chalian VA, Hutton C. An intraoral positive-pressure device for treatment of trismus. Oral Surg. 1986;61(5):456-458.
Buchbinder D, Currivan RB, Kaplan AJ, et al. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: A comparison of three techniques. J Oral Maxillofac Surg. 1993;51(8):863-867.
Friedman MH. Closed lock. A survey of 400 cases. Oral Surg Oral Med Oral Pathol. 1993;75(4):422-427.
King GE, Toth BB, Fleming TJ. Oral dental care of the cancer patient. Tex Dent J. 1988;105:10-11.
No authors listed. National Institutes of Health Consensus Development Conference Statement: Oral complications of cancer therapies: Diagnosis, prevention, and treatment. J Am Dent Assoc. 1989;119(1):179-183.
Toth BB, Martin JW, Fleming TJ. Oral and dental care associated with cancer therapy. Cancer Bull. 1991;43:397-402.
Toth BB, Frame RT. Dental oncology: The management of disease and treatment-related oral/dental complications associated with chemotherapy. Curr Probl Cancer. 1983;7:7-35.
Toth BB, Martin JW, Fleming TJ. Oral complications associated with cancer therapy: An M.D. Anderson Cancer Center experience. J Clin Periodontol. 1990;17:508-515.
Schweiger JW. Oral complications following radiation therapy: A five-year retrospective report. J Prosthet Dent. 1987;58:78-82.
Fleming TJ. Oral tissue changes of radiation-oncology and their management. Dent Clin North Am. 1990;34:233-237.
Barrett VJ, Martin JW, Jacob RF, et al. Physical therapy techniques in the treatment of the head and neck patient. J Prosthet Dent. 1988;59:343-346.
Rocabardo M, Johnston BE, Blakney MG. Physical therapy and dentistry: An overview. J Craniomand Pract. 1983;1:46-49.
Therabite Corporation. Therabite Jaw Motion Rehabilitation System. West Chester, PA: Therabite; 2002. Available at: http://www.therabite.com. Accessed December 9, 2002.
Gaziano JE. Evaluation and management of oropharyngeal dysphagia in head and neck cancer. Cancer Control. 2002;9(5):400-409.
Maloney GE, Mehta N, Forgione AG, et al. Effect of a passive jaw motion device on pain and range of motion in TMD patients not responding to flat plane intraoral appliances. Cranio. 2002; 20(1):55-66.
Nicalaou N. Prevention and management of radiation toxicity. In: Cancer Management: A Multidisciplinary Approach. 7th ed. R Pazdur, LR Coia, WJ Hoskins, LD Wagman, eds. Melville, NY: PRR; 2003; Ch. 46: 909-939.
Dijkstra PU, Kalk WW, Roodenburg JL. Trismus in head and neck oncology: A systematic review. Oral Oncol. 2004;40(9):879-889.
Cohen EG, Deschler DG, Walsh K, Hayden RE. Early use of a mechanical stretching device to improve mandibular mobility after composite resection: A pilot study. Arch Phys Med Rehabil. 2005;86(7):1416-1419.
McNeely Ml, Olivo SA, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006;86(5):710-725.
Gibbons AJ, Abulhoul S. Use of a Therabite appliance in the management of bilateral mandibular coronoid hyperplasia. Br J Oral Maxillofac Surg. 2007;45(6):505-506.
Wenghoefer M, Martini M, Anwander T, et al. Hyperplasia of the coronoid process: Diagnosis and treatment. Mund Kiefer Gesichtschir. 2006;10(6):409-414.
Fernández Ferro M, Fernández Sanromán J, Sandoval Gutierrez J, et al. Treatment of bilateral hyperplasia of the coronoid process of the mandible. Presentation of a case and review of the literature. Med Oral Patol Oral Cir Bucal. 2008;13(9):E595-E598.
Melchers LJ, Van Weert E, Beurskens CH, et al. Exercise adherence in patients with trismus due to head and neck oncology: A qualitative study into the use of the Therabite. Int J Oral Maxillofac Surg. 2009;38(9):947-954.
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.