What treatments are covered by medical insurance for TMD/TMJ?
The great news is – there are several different treatments that are considered medically necessary for the treatment of temporomandibular disorders (TMD’s) by medical insurers! However, not all services and treatments are covered, and will be listed as “experimental and investigational” in the insurer’s medical policy.
There are three very important things to keep in mind:
1) Not all patient’s medical plans offer coverage for TMD/TMJ, so it is important to verify this during a benefit check for your patient!
2) The insurer will list the services considered medically necessary with a diagnosis of TMD (as well as the services that are not) in the medical policy for treatment of temporomandibular disorders, so check the medical policy when you begin working with a new medical insurer!
3) Most insurers will require an actual TMD diagnosis for these services to be covered when the claim is filed….. simply a pain/headache diagnosis does not suffice! For more information on TMD diagnosis codes – see our tip of the week on TMD diagnosis codes:
http://dentalwriter.com/....aspx?g=posts&t=344
Here is an example of a medical policy for Temporomandibular Disorders from Aetna:
http://www.aetna.com/cpb/medical/data/1_99/0028.htmlAetna’s policy lists the following non-surgical procedures as medically necessary (unless contraindicated):
• Reversible Intra-Oral Appliances
• Physical Therapy
• Pharmacological Management
• Relaxation Therapy and Cognitive Behavioral Therapy (CBT)
• Acupuncture and Trigger Point Injections
• Manipulation for reduction of fracture or dislocation of the TMJ is considered medically necessary.
Aetna’s policy also goes on to list the surgical procedures that are considered medically necessary as well.
There is generally a section of the medical policy that addresses the non-covered or procedures considered “experimental and investigational” as well.
**This doesn’t mean these services will never be covered, they just aren’t right now! Generally, once the insurer has enough evidence – meaning clinical studies and success rates – the treatment will move to the covered list!
For example – Aetna’s policy lists the following as currently experimental and investigational for the treatment of TMD:
• Diagnostic procedures
o Cephalometric or lateral skull x-rays
o Computerized mandibular scan/kinesiography/electrogathograph/jaw tracking
o Diagnostic study models
o Electromyography (EMG), surface EMG (see CPB 0112 - Surface Scanning and Macro Electromyography)
o Electronic registration (Myomonitor)
o Joint vibration analysis
o Muscle testing/range of motion measurements (incidental to examination)
o Neuromuscular junction testing, somatosensory testing
o Sonogram (ultrasonic Doppler auscultation)
o Standard dental radiographic procedures
o Thermography (see CPB 0029 - Thermography)
• Non-surgical treatments
o Botulinum toxin (type A or type B) (however, botulinum toxin type A is considered medically necessary for jaw-closing oromandibular dystonia -- see CPB 0113 - Botulinum Toxin)
o Continuous passive motion (see CPB 0010 - Continuous Passive Motion (CPM) Machines)
o Cranial (craniosacral) manipulation (see CPB 0388 - Complementary and Alternative Medicine)
o Dental restorations/prostheses (see CPB 0082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans)
o Diathermy, infrared, and ultrasound treatments
o Dry needling
o Hydrotherapy (immersion therapy, whirlpool baths)
o Iontophoresis (see CPB 0229 - Iontophoresis)
o Intra-articular injection of hyaluronic acid (viscosupplementation)
o Intraoral appliances for headache or trigeminal neuralgia (see CPB 0688 - Intra-oral Appliances for Headache and Trigeminal Neuralgia)
o Irreversible occlusion therapy aimed at modification of the occlusion itself through alteration of the tooth structure or jaw position
o Ketamine (local/intra-articular administration)
o Low level (cold) laser (see CPB 0363 - Cold Laser and High-Power Laser Therapies)
o Myofunctional therapy
o Myomonitor treatment (J-4, BNS-40, Bio-TENS)
o Neuromuscular re-education
o Orthodontic/bite adjustment services and orthodontic fixed appliances (see CPB 0095 - Orthognathic Surgery; and CPB 0082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans)
o Prophylactic management of TMJ disorder, including occlusal adjustment
o Radiofrequency generator thermolysis (see also CPB 0400 - Ernest or Eagle's Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis)
o Therabite Jaw Motion Rehabilitation System (see CPB 0412 - Therabite Jaw Motion Rehabilitation System)
o Transcutaneous electrical nerve stimulation (TENS) (see CPB 0011 - Electrical Stimulation for Pain)
But remember, every medical insurer’s medical policy is slightly different! Be sure to check the medical policy for the insurer you are working with for the covered and non-covered services. Here are a few more examples of medical policies for treatment of TMD:
United HealthCare:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/TMJ_CDG.pdf
Blue Shield of CA:
https://www.blueshieldca.com/provider/content_assets/documents/download/public/bscpolicy/TMJ_Dysfunction.pdfCigna:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0156_coveragepositioncriteria_tmj_disorder_surgery.pdf