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 13

  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.

  6. My disc is ripped to shreds. Every single movement of my jaw– I hear and feel bone on bone. The pain is immense and I often have to put pressure on my joint externally to keep it in place. I had a disc replacement surgery on the other side almost 30 years ago and I have no problems with that one. I understand that the surgery is no longer performed since silicone recall. My insurance categorically denies “disorders of the TMJ”. Is a ripped up disc considered a “disorder of the TMJ” or are there other codes that might apply? What makes it hard is that my husbands company has self-funded insurance- and people have lost their jobs when high insurance claims were submitted (of course that was not the stated reason for job loss….)

  7. I have had TMJ surgery in 1986 however my doctor retired . I now have a 6 part bridge on tge lower side that isn’t doing well so i can’t wear night plate.

    I have medicare & medigap. I do have dental insurance.

    Dr Shapira Response:

    The first step is to have the bridge evaluated. You will not get medical coverage but your dental insurance may pay for some of treatment.

    Contact my office at 847-623-5530

    Ira L Shapira DDS, D,ABDSM, D,AAIPM, FICCMO, MICCMO
    Past Chair, Alliance of TMD Organizations
    Diplomat, Academy of Integrative Pain Management
    Diplomate, American Board of Dental Sleep Medicine
    Diplomate, American Board Sleep and Breathing
    Regent, Master & Fellow, International College of CranioMandibular Orthopedics

    Board Eligible, American Academy of CranioFacial Pain
    Professor Neuromuscular Orthodontics and CranioMandibular Orthopedics University of Castellon
    Dental Section Editor, Sleep & Health Journal
    CranioFacial Pain Section Editor, CRANIO: Journal of Craniomandibular and Sleep Practice
    Member, American Equilibration Society

    Member, Academy of Applied Myofunctional Sciences
    Member, Academy of Cosmetic Dentistry
    Life Member, American Dental Association
    http://www.ThinkBetterLife.com
    http://www.DelanyDentalCare.com
    http://www.NorthShoreSleepDentist.com
    http://www.IHateCPAP.com
    http://www.iHateHeadaches.org
    http://www.SleepandHealth.com
    http://www.SphenopalatineGanglionBlocks.com
    https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg

  8. I’m having this issue with insurance I am suffering from severe tmd currently
    My pain is off the charts!!!!!
    I feel like now the muscles, tendons and ligaments are not even working on the right side of my jaw. . All the work (opening/closing) is being done by only the left side. I feel like something is very wrong. I have Medicare/ Medicaid it’s impossible to find any specialist that will do treatment or take this insurance etc

    1. Post
      Author

      Insurance companies are almost never sympathetic when discussing covering TMD treatment.
      TMJ Disorders.

      First step is stabilization, 24/7

  9. My dentist recommended a short course with braces to realign my bite arch. They said it wouldn’t be covered since insurance “only covers braces for 26 or under”, but if this is to treat the tmj/ridiculous amount of grinding i do why can’t it be put under tmj treatment which would cover 1/2of the quoted cost (i have a lifetime max for tmj). Is there anything that would help in getting insurance to cover?

    1. Post
      Author

      Jennifer,
      Two issues the first is insurance coverage. Insurance companies have done everything possible to avoid covering TMJ Disorders. It is possible to get medical coverage for some orthodontic treatments.

      The second issue is more of a problem. If moving the teeth make the problem worse or much worse they are not reversible.

      Normally, reversible treatment is safer until symptoms are controlled

  10. I forgot the pivotal question:
    What do I tell my gp to get treatment? He has been biased about my arthritis and disc issues . I cant go on like this. Mom is wheel chair bound and I cant go to store/drive except 1 day every so many weeks. The vertigo and migraines.

    Dr Shapira response: Typically, patients directly contact trained dentists. If you are required to have a medical referral have a clear WRITTEN list of symptoms. Keep it short and ask for referral

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