TMJ issues should be covered by insurance, according to most experts. Many people wonder whether it’s covered by medical or dental insurance, and where the boundary is that separates the two types of coverage.
Medical insurance is usually the primary source of coverage for TMJ issues. The reason for this is that a joint, like muscle, tendons, and ligaments, can be found everywhere in the body. Physical therapy coverage is normally straightforward, although coverage conflicts are common when orthotics, appliances, or splints are created.
Blue Cross and Red Crescent Societies When used to treat a TMJ patient, Blue Shield will generally classify TENS as experimental, but will pay treatment for other purposes.
It’s worth noting that treating TMJ issues saves both patients and insurance companies money.
TMD sufferers used healthcare at 200-300 percent higher rates than non-TMJ patients, according to Shimshak et al’s findings published in Cranio.
My personal experience with saving money for insurance companies dates back to the 1980s when I worked for Chicago HMO. I had a patient who really required treatment, but her insurance didn’t cover it. I struggled for coverage and eventually met with Dr Mitchell Trubitt, the Medical Director of Chicago HMO Ltd.
I described the treatment to him, and he agreed to the non-surgical treatment, which proved to be effective. We agreed to a trial period after I assured him I could save the insurance company money while also benefitting the patients. Six patients were sent to me by a Chicago HMO, all of whom were told they needed TMJ surgery.
I handled the first six patients, and after reviewing the records, Dr. Trubitt estimated that the non-surgical approach had saved the Chicago HMO over $250,000.
Dr. Trubitt then negotiated a preferred provider agreement with Chicago HMO, under which Chicago HMO would cover 100% of phase 1 TMJ treatment with no deductible. Because of the cost savings to the corporation, he also cut the physician’s referral fee to the same level as cancer and cardiac treatment, which was the lowest available.
The end product was fantastic. Almost all of the patients who were tentatively scheduled for TMJoint surgery were able to avoid it. It was less politically acceptable because many oral surgeons objected to their surgical patients being referred to a general dentist for non-surgical treatment. Dr. Bruce Douglas, who was a Board Certified in OMS and a prior editor of their magazine, and I developed a very good relationship since he was an amazing oral surgeon who did not like TMJ surgery.
This arrangement allowed me to work with Chicago HMO and Mitch Trubitt for many years until United Health Care purchased the company. I met with their medical director and Dr. Trubitt, but they informed me that they were not interested in continuing the program because they did not pay for surgery and would not see any savings.
The Shimshak study, which found a 300 percent increase in medical utilization among individuals with TMJ issues, had not yet been published. With the sale of Chicago HMO to United Health Care, a scheme that helped patients and physicians while also saving money came to an end.
The future of health care and coverage for TMD problems is still up in the air.
I am the current chair of the American Alliance of TMD Organizations, which works to represent the majority of dentists who treat TMJ issues in obtaining insurance coverage and protecting patients’ rights to receive adequate treatment.
Is TMJ usually covered by insurance?
TMJ is a potentially debilitating jaw disorder. Although it may appear to be minor at first, if left untreated, it can progress to severe pain or even full jaw paralysis. Except in the eyes of insurance, it’s actually no different than other joint disorders from some perspectives.
The temporomandibular joint and related diseases are treated differently by insurance companies than other forms of joint ailments, and most insurance companies refuse to cover them unless the state requires it. Unfortunately, Colorado is not one of the states that requires TMJ therapy to be covered.
That isn’t to say that your insurance won’t cover TMJ therapy; it just means that it probably won’t.
Is TMJ considered a medical or dental condition?
Patients who experience clicking or popping in the temporomandibular joint may have TMJ disorder, which is a combination of jaw joint and facial muscle dysfunction. Patients who are feminine, suffer from stress or anxiety, or have other health issues that impact the muscles and joints may benefit from a consultation. Because TMJ might be caused by a medical issue, a dental issue, or a mix of the two, it’s important to figure out what’s causing the patient’s condition before developing a treatment strategy.
Does medical insurance cover TMJ surgery?
YES! – Medical insurers consider various different treatments for the treatment of temporomandibular disorders (TMDs) to be medically required! However, not all services and treatments are covered, and those that are will be designated in the insurer’s medical policy as “experimental and investigational.”
- Because not all medical insurance cover TMD/TMJ, it’s critical to double-check this during your patient’s benefit check.
- The medical policy for treatment of temporomandibular disorders will list the services considered medically required with a diagnosis of TMD (as well as the services that are not), so verify the medical policy when you start working with a new medical insurer.
- For these therapies to be paid, most insurers will require a genuine TMD diagnosis when the claim is made…. merely a pain/headache diagnosis will not enough.
Aetna’s medical insurance for Temporomandibular Disorders looks like this:
The following non-surgical procedures are listed as medically required by Aetna (unless contraindicated):
- Manipulation of the TMJ is regarded medically required for the reduction of fractures or dislocations.
The surgical procedures that are considered medically necessary are likewise listed in Aetna’s policy.
Non-covered or “experimental and investigational” operations are typically addressed in a separate section of the medical policy.
**This isn’t to say that certain services will never be covered; they simply aren’t at the moment! In most cases, after the insurer has enough evidence such as clinical studies and success rates the treatment will be added to the list of covered treatments!
For example, according to Aetna’s policy, the following treatments for TMD are currently experimental and investigational:
- Surface electromyography (see CPB 0112 Surface Scanning and Macrolectromyography) is a type of electromyography.
- Botulinum toxin (type A or type B) (however, for jaw-closing oromandibular dystonia, botulinum toxin type A is regarded medically required see CPB 0113 Botulinum Toxin)
- CPB 0010 Continuous Passive Motion (CPM) Machines Continuous Passive Motion (CPM) Machines Continuous Passive Motion (CPM) Machines Continuous Passive Motion (CPM) Machines
- Manipulation of the cranium (craniosacral therapy) (see CPB 0388 – Complementary and Alternative Medicine)
- Restorative and prosthetic dental work (see CPB 0082 Dental Services and Oral and Maxillofacial Surgery: Medical Plan Coverage)
- Headache or trigeminal neuralgia intraoral appliances (see CPB 0688 Intra-oral Appliances for Headache and Trigeminal Neuralgia)
- Irreversible occlusion therapy involves changing the tooth structure or jaw position in order to change the occlusion.
- Cold laser (see CPB 0363 Cold Laser and High-Power Laser Therapies) is a low-level (cold) laser.
- Orthodontic/bite adjustment services and orthodontic fixed appliances are covered under medical plans (see CPB 0095 Orthognathic Surgery and CPB 0082 Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans).
- Ernest or Eagle’s Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis (see also CPB 0400 Ernest or Eagle’s Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis)
- CPB 0412 Therabite Jaw Motion Rehabilitation System Therabite Jaw Motion Rehabilitation System Therabite Jaw Motion Rehabilitation System Therabite Jaw Motion Rehabilitation System Therabite Jaw Motion Rehabilitation System The
- TENS (see CPB 0011 Electrical Stimulation for Pain) is a type of transcutaneous electrical nerve stimulation.
But keep in mind that each medical insurer’s policy is slightly different! Check the medical policy of the insurer you’re working with to see what services are covered and what aren’t.
Is Botox for TMJ covered by insurance?
Currently, medical insurance policies do not cover the use of BOTOX for TMJ issues. Because TMJ disorders are primarily a dental condition, it’s possible that insurance companies will eventually pay BOTOX injections as a way to prevent gum and tooth damage caused by excessive jaw grinding. Despite the fact that insurance companies have yet to cover this treatment, it is gaining popularity among patients, doctors, and dentists.
Can you get disability for TMJ?
The shock-absorbing disk erodes or slides out of position, the joint’s cartilage is destroyed by arthritis, or the joint is harmed by a blow or other trauma, all of which can cause painful TMJ dysfunction. In many situations, however, the reason of TMJ dysfunction is unknown. As a result of their military service, many veterans develop TMJ. You may be eligible for VA disability compensation if you are a veteran who believes your TMJ is caused by your service.
What can be mistaken for TMJ?
You have two trigeminal nerves that govern your jaw, just like you have two temporomandibular joints on each side of your face. It’s simple to see why TMJ problem is frequently misdiagnosed as nerve dysfunction. Irritation of the trigeminal nerves causes intense pain in the face, teeth, and around the ear, as well as numbness or tingling on one side of the face. Trigeminal neuralgia pain, unlike TMJ discomfort, is characterized by a sensation of electric shock.
What type of doctor treats jaw issues?
Tooth decay, sinus difficulties, arthritis, and gum disease are just a few of the illnesses that create comparable symptoms. The dentist will ask about your medical history and perform a physical check to determine what is affecting yours.
They’ll listen for clicks, pops, or grating sounds as you move your jaw joints, looking for pain or tenderness. They’ll also check to see if your jaw is working properly and doesn’t lock when you open or close your mouth. They’ll also assess your bite and look for issues with your face muscles.
To rule out other concerns, your dentist may take full-face X-rays to see your jaws, temporomandibular joints, and teeth. Other tests, such as magnetic resonance imaging (MRI) or computer tomography, may be required (CT). When your jaw moves, the MRI can show if the TMJ disc is in the appropriate position. The bone detail of the joint can be seen on a CT scan.
For additional care and treatment, you may be sent to an oral surgeon (also known as an oral and maxillofacial surgeon). This surgeon specializes in procedures involving the entire face, mouth, and jaw. You could also visit an orthodontist to confirm that your teeth, muscles, and joints are functioning properly.
Can a chiropractor fix TMJ?
TMJ treatment will have to be evaluated on a case-by-case basis. There is no one-size-fits-all cure for TMJ, which can be caused by anything from jaw injuries to stress. Upper cervical chiropractic, which focuses on re-aligning important parts of the upper spine, has been cited as an effective set of treatments in the past. Until a better chiropractic jaw adjustment is obtained, the chiropractor can additionally deal with critical muscles such the masseter, temporalis, and pterygoid.
Aside from expert chiropractic TMJ therapy, you can expect tangible instructions and advice on at-home exercises and stretches that can work in tandem with chiropractic care to help ease discomfort and stress in the jaw at Dr.chiropractic Lanoue’s clinic.
Do you have a TMJ problem? Dr. Lanoue and his Mississauga chiropractic staff may be able to stop the pain in its tracks! Please contact us for a no-obligation consultation.
How do braces fix TMJ?
Orthodontic braces are a good choice, especially if TMJ is caused by a malocclusion or bite misalignment. Braces will realign your bite, correcting the position of your teeth and jaw, potentially alleviating or eliminating additional symptoms.