There is a great deal of disagreement between insurance companies about whether TMJ problems are considered medical or dental. Insurance companies will try to avoid covering the cost of temporomandibular joint related claims for several reasons.
- The cause and treatment of TMJ disorder is very controversial.
- Since there is little scientific research, there are many treatments for TMJ disorder that not only do not work, they are known to make the patient’s TMJD worse. This allows insurance companies to pass the responsibility of the TMJ back and forth between medical and dental insurance without committing to either (and sometimes denying coverage for any treatment at all). Unfortunately, it is understandably difficult for an insurance company to consider paying for any treatment that is not proven to be successful, like splint therapy.
Steps to finding out more information about your TMJ disorder coverage:
- Call your insurance company and ask if there are any limits on TMJ disorder coverage. Be sure to have a copy of your benefits (and if you do not have one, ask for one to be mailed/faxed to you).
- Call both medical and dental insurance providers.
- IMPORTANT: Write down the date, time, the name of the person you talked with, and what they said. If they promise any type of coverage, have them send you a written verification of this coverage.
- If you are having a TMJ MRI or CT, ask about obtaining pre-authorization.
- If considering TMJ surgery, ask the surgeon to send your insurance company a “letter of medical necessity,” which details why you need the surgery, what the procedure entails, any hospital stays, etc. This is the first step in getting approval for jaw surgery.
- Call often after the letter of medical necessity is sent. Repeat step 3 every time you call.
- While waiting for approval, call your state insurance commissioner and ask what coverage must be provided for TMJ treatments in your state. Some states require insurance companies to pay a certain amount towards TMJ disorder treatment and/or surgery, some require them to treat the TMJ like any other joint, and some do not require insurance companies to pay for any TMJD treatment what so ever.
- If you are denied coverage for your treatment or surgery, ask that the appeal process be explained to you. Document everything. Ask that the denial be sent to you via mail or fax as well.
- Submit your appeal according to their process guidelines. Be sure that your surgeon or doctor is aware of what is happening and see if he or she has any advice for you (it is possible that the doctor may have gone through many previous appeals with your specific insurance company, and may be familiar with the process).
- Ask the insurance company when to expect an answer to your appeal. They only have a certain amount of time to get back to you with a decision.
- If after the appeal, the insurance company still denies your TMJ treatment or surgery, you have the choice to contact an attorney if you choose to.
Questions to ask your insurance company when determining coverage:
- Do you cover diagnostic services for TMJ disorder (imaging, testing, initial exam)? If so, what is specifically covered?
- Is there a lifetime benefit limit on TMJ disorder treatment/surgery? If so, what is it? What is included in this limit? If surgery is included in this limit, does that also include the anesthesiologist and hospital fees, or just the oral surgeon’s fee?