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TMJ Diseases & Disorders - Insurance
Insurance
Insurance coverage varies from state to state, company to company, and policy to policy. Some policies have specific exclusion clauses for the TMJ, some have limitations on the dollar amount or type of coverage available, such as only covering surgical procedures. Insurance companies generally try to avoid covering the cost of treating TMJ-related claims for several reasons. First, there is too much controversy about the causes and proper treatment of the problem. Second, there is little scientific validation of TMJ therapies. Indeed, some treatments appear to cause new TMJ problems or exacerbate existing ones. Arguments continue regarding the issues of whether TMJ treatments should be categorized as dental, medical, or even cosmetic. Because most insurance companies have not established targeted criteria-based benefits for TMJ problems, patients are not protected or are denied rightful coverage.
You may find that some of your TMJ treatment is considered medical, and some is considered dental. This means that you may have to go through the added complication of dealing with both your medical and dental insurers.
Our best recommendation at this time is that you first speak to your benefits coordinator. Call your state insurance commissioner to ask what coverage must be provided for TMJ treatments in your state for both regular insurance policies and the self-insured plans many major employers provide. If you're not receiving the type of coverage mandated by law, call your insurance company. Take careful notes on the conversations you have with your insurers and health care professionals. Include names, dates and complete descriptions of your discussions.
If after speaking with your insurance company's customer service department you are not granted coverage, ask for a claims supervisor. If that is not effective, search your health and dental plans for information on the appeals process. Appeals are not easy, but they might be the best way for you to get coverage. If need be, consult an attorney who specializes in this area.
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