DESCRIPTION
Intraoral devices are proposed as a treatment of headache (e.g., migraine, tension-type). An example of an intraoral device developed for the prophylactic prevention of headache is the Nociceptive Trigeminal Inhibition Tension Suppression System or NTI-tss®. This device fits over the two maxillary central incisors and has a dome-shaped protrusion which extends lingually. The dome is customized by the provider to act as single point contact at the incisal embrasure of the two mandibular central incisors, thereby preventing posterior or canine tooth contact.
POLICY
Intraoral devices for the prophylactic treatment of headaches are considered investigational.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Well-designed studies published in peer-reviewed journals are lacking regarding the use of any intraoral device for the treatment of headaches.
SOURCES
Almasan, O., Hedesiu, M., Leucuta, D-C., Buduru, S., & Dinu, C. (2022). Oral splints in the management of nociceptive pain and migraines: A scoping review. Experimental and Therapeutic Medicine, 25 (1), 28. (Level 3 evidence)
American Headache Society and American Academy of Neurology. (2012). The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines. Retrieved July 22, 2020 from https://americanheadachesociety.org/resources/guidelines/guidelines-position-statements-evidence-assessments-and-consensus-opinions/.
Bruno, M.A.D., & Krymchantowski, A.V. (2018). Amitriptyline and intraoral devices for migraine prevention: a randomized comparative trial. Arquivos de neuro-psiquiatria, 76 (4), 213-218. (Level 4 evidence)
Franco, L., Rompre, P., de Grandmont, P., Abe, S., & Lavigne, G. (2011). A mandibular advancement appliance reduces pain and rhythmic masticatory muscle activity in patients with morning headache. Journal of Orofacial Pain, 25 (3), 240-249. (Level 3 evidence)
Stapelmann, H., & Turp, J. C. (2008). The NTI-tss® device for the therapy of bruxism, temporomandibular disorders, and headache - where do we stand? A qualitative systematic review of the literature. BMC Oral Health, 8 (22). (Level 2 evidence)
U. S. Food and Drug Administration. (2001, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K010876 (NTI-tts®). Retrieved February 6, 2012 from http://www.accessdata.fda.gov.
ORIGINAL EFFECTIVE DATE: 9/1/2002
MOST RECENT REVIEW DATE: 12/14/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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