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What treatments are covered by medical insurance for TMD/TMJ?

Medical coverage for treatments of 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.


Here is an example of a medical policy for Temporomandibular Disorders from Aetna:
http://www.aetna.com/cpb/medical/data/1_99/0028.html 

Aetna’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
oCephalometric or lateral skull x-rays
oComputerized mandibular scan/kinesiography/electrogathograph/jaw tracking
oDiagnostic study models
oElectromyography (EMG), surface EMG (see CPB 0112 - Surface Scanning and Macro Electromyography)
oElectronic registration (Myomonitor)
oJoint vibration analysis
oMuscle testing/range of motion measurements (incidental to examination)
oNeuromuscular junction testing, somatosensory testing
oSonogram (ultrasonic Doppler auscultation)
oStandard dental radiographic procedures
oThermography (see CPB 0029 - Thermography)

•Non-surgical treatments
oBotulinum 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)
oContinuous passive motion (see CPB 0010 - Continuous Passive Motion (CPM) Machines)
oCranial (craniosacral) manipulation (see CPB 0388 - Complementary and Alternative Medicine)
oDental restorations/prostheses (see CPB 0082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans)
oDiathermy, infrared, and ultrasound treatments
oDry needling
oHydrotherapy (immersion therapy, whirlpool baths)
oIontophoresis (see CPB 0229 - Iontophoresis)
oIntra-articular injection of hyaluronic acid (viscosupplementation)
oIntraoral appliances for headache or trigeminal neuralgia (see CPB 0688 - Intra-oral Appliances for Headache and Trigeminal Neuralgia)
oIrreversible occlusion therapy aimed at modification of the occlusion itself through alteration of the tooth structure or jaw position
oKetamine (local/intra-articular administration)
oLow level (cold) laser (see CPB 0363 - Cold Laser and High-Power Laser Therapies)
oMyofunctional therapy
oMyomonitor treatment (J-4, BNS-40, Bio-TENS)
oNeuromuscular re-education
oOrthodontic/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)
oProphylactic management of TMJ disorder, including occlusal adjustment
oRadiofrequency generator thermolysis (see also CPB 0400 - Ernest or Eagle's Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis)
oTherabite Jaw Motion Rehabilitation System (see CPB 0412 - Therabite Jaw Motion Rehabilitation System)
oTranscutaneous 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.pdf

Cigna:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0156_coveragepositioncriteria_tmj_disorder_surgery.pdf