TMJ And Insurance: Everything You Need To Know

TMJ And Insurance: Everything You Need To Know

Temporomandibular Joint Disorder (also known as TMJ, TMD, or TMJD) is a disease that medical insurance carriers still question.

Many medical and dental insurance companies do not offer TMJ insurance to cover the treatment therapies or manage the issue.

This leads to people resorting to home therapies for TMJ relief.

Those that do offer insurance for TMJ, often have many steps that need to take place to prove its diagnosis before treatment. There are many reasons for this.

The main reason is that TMJ is difficult to prove and does not have an immediate cure.

It is often proven by eliminating other diseases and possibilities.

Defining TMJ

TMJ has a broad definition.

12% of the population suffer from this disorder according to U.S. News And World Reports.

It causes pain in the jaw due to the jaw joint being misaligned.

This could be due to the mandible (jaw bone) being misformed, the muscles that control it not working properly, or a combination of both.

Possible causes can be from arthritis, a misaligned bite, dislocation of the jaw, or the results of an injury according to Delta Dental Insurance.

Symptoms of TMJ include:

  • Headache
  • Earache
  • Ear ringing
  • Nausea
  • Fatigue
  • Neck pain
  • Tinitious (numbness or tingling) in the hands or fingers

Statistically, twice as many women suffer from it than men.

Of those women, it usually starts up in women that are within their childbearing years (as a time frame, not due to the changes women go through during pregnancy).

A theory supports the idea that because estrogen does affect inflammation, this could be why women are affected more.

Strenuous activity or high stress has also been attributed as a cause for TMJ.

Current treatment methods include:

  • Physical Therapy
  • Anti-inflammatory, muscle relaxants, and pain medication
  • Acupuncture
  • Massage
  • Sleep studies
  • Botox
  • Relaxation therapy
  • Cognitive behavioral therapy
  • In extreme cases, surgery

The Problem With Diagnosing TMJ

According to an article written by the Harvard Medical School, TMJ is difficult to diagnose because it looks like so many other disorders.

It is often misdiagnosed due to pain radiating to the jaw from other issues that come from the teeth,neck, spine, brain, migraines, or anxiety.

Dentist and doctors disagree with how to consider TMJ.

Many dentists consider it medical, and doctors believe it is primarily dental.

Unless they specialize in jaw diseases, dentists are not thoroughly trained to treat patients with the disorder.

The history behind Temporomandibular Joint Disorder shows many examples of overtreatment with surgery.

In the 1970s and 1980s, specialists believed that surgery was the best option.

They also attributed TMJ just to a bad bite alignment causing irregular strain on the mandibular joint and muscles.

After further study, in the 1990s, the philosophy changed to look at the whole picture of the symptoms.

Doctors and oral surgeons now look at the relationship of the symptoms and where they come from.

They then test for more obvious diseases first.

Using this method, TMJ is diagnosed once all other possibilities have been proven to be false.

How TMJ Is Covered By Insurance

Insurance for TMJ can be difficult to find.

It is covered by some dental and medical insurances according to Chicago Insurance Online.

The Affordable Care Act mandates insurance providers cover a list of diseases.

Unfortunately, TMJ is not one of them.

20 different states have required insurance companies to provide TMJ insurance.

  • Arkansas
  • Connecticut
  • Florida
  • Georgia
  • Illinois
  • Kentucky
  • Maryland
  • Minnesota
  • Mississippi
  • North Carolina
  • North Dakota
  • Nebraska
  • New Mexico
  • Nevada
  • Texas
  • Virginia
  • Vermont
  • Washington State
  • Wisconsin
  • West Virginia

If you live in one of these states, contact your medical insurance carrier to find out how they cover TMJ.

Another way that TMJ medical costs can be covered is if the disorder is caused through a workplace injury or accident caused by a third party.

Worker’s compensation, auto insliurance and other settlement-based coverages have a medical component to them.

Your settlement may not cover some costs (depending on the agreed upon amount), but it could reduce your own out-of-pocket responsibilities.

Example: Aetna Coverage Of TMJ

An example of how an insurance company does provide insurance for TMJ is Aetna.

Some of their HMO plans do not have TMJ insurance coverage.

For those HMO and PPO plans that do cover TMJ, their Oral and Maxillofacial Surgery Department must review the case.

They require the following:

  • Their Aetna TMJ Questionnaire
  • A Physical and/or Psychological Exam
  • Radiograph/ Diagnostic Imaging (X-Ray, CT, and/or MRI)

You'll also need medical records from the past 3-6 months of non-surgical treatment (if seeking surgery) that notate:

  • The type of treatment being requested
  • The results from the treatment
  • Specific findings
  • A proposed treatment plan from the medical/dental professional primarily handling the patient’s case

Aetna also requires the patient tries a number of non-surgical treatments for at least 3 months.

If surgery is determined after that, then they will cover the least invasive types of surgery possible.

Tips On How To Talk To Your Insurance Company

Finding a medical insurance company that covers TMJ is difficult.

Even if the company has policies that cover it, your specific plan may not have the coverage in it.

Here are some tips when speaking with your insurance company.

Identify The Exact Plan You Have

Medical and Dental insurance companies have different coverage plans with identity numbers or titles.

Make sure you know the exact plan you have and read through the coverage literature they provide you.

For example, Blue Cross Blue Shield Of Texas has a procedure for covering TMJ that applied to that specific state. Blue Cross Blue Shield in a different state may not.

Get It In Writing

After you discuss your case with the insurance company representative, and you are approved, ask them to send an approval letter to you.

Have this letter detail specifics on what treatments are covered.

Get Your Doctor Involved

Your doctor has access to departments and decision-makers that you do not.

They can also discuss your case with the insurance doctors on a medical level more specific than what you can provide.

Employer Coverage Advantages

Employer medical coverage can have additional coverages that individual policies do not.

With the greater amount of people covered in the group policy, it is still cost effective to the insurance company to offer additional coverages.

Check with your human resources department to find out the details of your policy.

If your company’s policy does not cover it, ask the HR team to look into the possibility of getting the coverage.

Surgery Is Not Always The Best Option

Many people believe that having surgery can fix TMJ disorder.

The reality is that surgery can come with its own complications after the procedure.

Scar tissue can build up that limits the mobility of the joint, or cause further pain.

Arthritis can develop after a few years that causes more pain than what you started with. There are numerous other effects from surgery that can occur as well.

Be open to pain management or other therapies that may help you with managing or reduce the symptoms.

When you are in pain, all you want to do is stop it.

You expect your insurance carrier to cover the costs of your medical treatments the way you expect.

The truth of the matter may be different and it can be a frustrating process.

The approval you do get may not be what you are expecting.

Insurance is one of the most heavily regulated industries in The United States.

Even before the Affordable Care Act, there were many requirements that the government put in place that medical insurance companies had to follow.

TMJ is not a simple disorder.

Appropriate treatment is more complicated than a broken bone or the flu.

The best way to get the coverage you need is to keep yourself informed. Research your medical coverage and others that are available to you.

Get involved with online TMJ groups that share information and offer support to those that suffer from it.

There could be someone out there in your area that has information you need.


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