Medical Insurance Coverage for TMJ Disorders (TMD)

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 .

Comments 6

  1. Good afternoon this is Cristia McClain,I am in need of more information about what type of medical coverage cover’s tmj tmd treatment.I am a caregiver for ihss & my current client is suffering from tmj tmd related issues.
    I look foward to hearing back from someone when available
    Thank You

    1. Post
      Author

      There are many specific medical diagnostic codes that can be used with matching CPT codes. many insurance companies recode all dental submissions as TMJ and frequently deny.

  2. Pingback: Coverage for TMD | Dental Insurance Verification

  3. I am on medicare and Medicaid. I have been diagnosed with severe TMJ. Severe arthritis in jaw . Does my medical condition covered by insurance . As I am unable to afford due to Disability income . Not to take advantage of insurance just a condition is medically that makes life harder due to pain and many other physical side affects .

    My practice does not accept either Medicare or Medicaid. Typically TMD treatment is not covered well by medical insurance. I suggest finding an Oral Surgeon in Medicare / Medicaid who treats TMJ disorders.

  4. Hi I have frequent jaw dislocayions amd I have BCBS of Oklahoma. Im in the ER at least once a month. ER doctors always telling me I need to get surgery or my jaw fixed. But problem is my insurance will not pay for any surgeries that I need to help my jaw. They wont because the jaw is the Tmj joint. But everytime I go to the ER to get my jaw back In place my insurance will pay for those visits. I cant afford surgery out od pocket. So You have any sugestions what I should do.

    Dr Shapira Resposne: Insurance companies can cover something that is excluded in the contact.

    There is a California court decision on the Wickline case where the court ruled Insurance companines and any responsible for pain and suffering duelack of care can be sued regardless of contract language if the patient is hurt. The first step is the doctor and health care providers must make a formal complaint about denial of care.

  5. I live in Oklahoma. ButI do suffer a lot. I have severe migraines when my jaw goes out or on the verge of going out. I have lost 2 jobs from this because I had to miss so much time. One of my oral doctors even wrote a letter for my insurance explaining the pain and suffering I go trough but was no good.

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