Subject: Intraoral Appliances for Headaches
Date: June 22, 2015
This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.
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 refer to 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.
Aetna considers intra-oral appliances (for example, the Nociceptive Trigeminal Inhibition-Tension Suppression System) experimental and investigational for the treatment of headaches and trigeminal neuralgia because their effectiveness for these indications has not been established.
Original policy: November 4, 2004
Updated: September 25, 2006; August 26, 2008; June 27, 2011; July 12, 2012; August 12, 2013; June 9, 2014; June 22, 2015
Revised: November 16, 2009
Medical Clinical Policy Bulletin 0688: Intraoral Appliances for Headaches and Trigeminal Neuralgia. This CPB was reviewed and maintained on October 30, 2014.
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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