Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Temporomandibular joint osteolysis, Arthritic condylar lysis, Systemic arthritides

Treatment: Durable Medical Equipment (OraStretch press jaw rehab system)

The insurer denied coverage for Durable Medical Equipment (OraStretch press jaw rehab system).

The denial is overturned.

This is a female patient with a history of rheumatoid arthritis, temporomandibular joint (TMJ) osteolysis, arthritic condylar lysis, Sicca syndrome and obstructive sleep apnea. She was evaluated and treated with a Lefort 1 osteotomy and total joint replacement. The patient has been diagnosed with systemic arthritides. The patient has continued to experience limited oral opening, and the treatment plan was for an OraStretch device. This device was intended to allow for oral manipulation and to aid in increasing this patient's oral opening to normal baseline.

According to Santiago-Rosado and Lewison (2020), "Treatment of trismus is directed at the inciting etiology and is most commonly treated symptomatically. Symptom-directed interventions including heat therapy, analgesics such as non-steroidal anti-inflammatory agents, and muscle relaxants may be considered in the acute phase and have been described as mainstays of treatment of uncomplicated transient trismus. Patients with post-traumatic and post-operative trismus, especially when persisting longer than 1 week, may also require stretching exercises. The exercises typically consist of repeated attempts to open the mouth against applied resistance, usually divided into multiple sessions per day. Trismus may become chronic in the setting of fibrosis or ongoing radiotherapy; these cases may benefit from intensive physiotherapy, sometimes utilizing commercially-available jaw motion rehabilitation devices or microcurrent therapy, particularly in cases refractory to more conservative approaches." And as per Pauli et al (2015), "Jaw exercise therapy effectively improved mouth opening capacity and led to less trismus-related symptoms. Both jaw devices were proved efficient and compliance to exercise was comparable."
                                          
Based on the review of the medical record and literature, OraStretch device is considered medically necessary for this patient. This patient has developed post-surgical limited oral opening after total joint replacement. The treatment of this patient can be multifaceted. This includes passive and active oral devices as well as physiotherapy, and even possibly surgery. The oral device allows the patient to increase oral opening daily. The use of oral appliances for trismus is well known and very common for TMJ surgical patients. These types of devices allow for return to increased oral opening for patients like in this case. Home physical therapy alone or in combination to physical therapy aids in returning the patient to a functional opening. These types of appliances are routinely used both passively and actively to treat TMJ patients and this request, Orastretch, should be considered medically necessary.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Durable Medical Equipment (OraStretch press jaw rehab system) should be overturned. The medical necessity is substantiated.