It is generally agreed that TMJ disorders should be covered by insurance. There are often questions whether it is covered by medical insurance or dental insurance and whee the line is that seperates coverage.
Medical Insurance typically is the primary insurance for TMJ disorders. The reason is that a joint is a joint anywhere in the body, as is muscle, tendons, and ligaments. Physical Therapy coverage is generally easy but when orthotics, appliances or splints are made coverage disputes often occur.
Blue Cross Blue Shield will often classify TENS as experimental when used for treating a TMJ patient but will cover treatment for other purposes.
The interesting fact is that covering TMJ disorders will usually save patients and insurance companies money.
Shimshak et al did studies published in Cranio that showed TMD patients utilized healthcare at 200-300% increased rates compared to non-TMJ patients.
My personal experience in saving insurance companies money goes back to the 1980’s with Chicago HMO. I had a patient who badly needed treatment but there was no coverage in her plan. I fought for coverage and eventually met with the Medical Director of Chicago HMO Ltd, Dr Mitchell Trubitt.
I explained to him treatment and he approved non-surgical treatment which was successful. I told him I could save the insurance company money while helping the patients and we agreed to a trial period. Chicago HMO sent me six patients all of whom were recommended TMJoint surgery.
I treated the first six patients and when reviewed the records Dr Trubitt estimated that the Chicago HMO had saved over $250,000 with the non-surgical appoach.
Dr Trubitt then arranged for a favored provider arrangement with Chicago HMO where 100% of phase 1 TMJ treatment was covered by Chicago HMO with no deductible. Because of the savings to the company he also reduced the physician’s cost of a referral to the same as cancer and cardiac care, the lowest offered.
The results were amazing almost 100% of patients who were tenatively scheduled for TMJoint surgery avoided surgery. It was less acceptable politically as many of the oral surgeons were not happy having their surgical patients referred to a general dentist for non-surgical therapy. I did develop a very close relationship with an excellent oral surgeon who did not like TMJ surgery, Dr Bruce Douglas who was a Board Certified in OMS and a previous editor of their journal.
I worked with Chicago HMO and Mitch Trubitt for many years under this arrangement until it was bought by United Health Care. I met with their medical director and Dr Trubitt but was told that they did not want to continue the program because they did not pay for surgery and would not see any savings.
The Shimshak study showing patients with TMJ disorders had a 300% increase in medical utilization had not yet been published. Unfortunately, a program that had benefited patients and physicians as well as saving money ended with the sale of Chicago HMO to United Health Care.
The future of health care and coverage of TMD conditions is still in question. I am the current chair of the American Alliance of TMD Organizations and we work representing the majority of dentists treating TMJ disorders to get insurance coverage and protect the rights of patients to get appropriate care .