Medical Insurance Coverage for TMJ Disorders (TMD)

November 19th, 2019 - Christine Taxin
Categories:   Billing   Dental   Oral and Maxillofacial Surgery   Claims  
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It is agreed that TMJ disorders should be covered by insurance. There are often questions whether it is covered by medical insurance or dental insurance and where the line is that separates coverage.
Medical Insurance typically is the primary insurance for TMJ disorders. The reason is that joints are found anywhere in the body, as are muscles, tendons, and ligaments. Physical Therapy coverage is easy, but when orthotics, appliances or splints are made, coverage disputes often occur.
Blue Cross Blue Shield will often classify TENS as experimental when used for treating a TMJ patient but will cover treatment for other purposes.
The interesting fact is that covering TMJ disorders will usually save patients and insurance companies money.
I have explained treatment and how, when you add the amount of savings to the patients’ medical plan, you will be approved for non-surgical treatment, which was successful. I go over the amount of money they are spending by having the patient go from doctor to doctor or having surgery rather than doing a non-surgical procedure. Show them in dollars.
I treated the first six patients and reviewed the records. Tracking your records and then contacting a manager to show them the saved money may just give you the incentive to be in-network for treatment of TMD, saving the medical plan around $100,000.00 per patient. Look at the fee for surgery, then track either your Botox or appliance to show them numbers. That is how an insurance company looks at claims.
If you are having trouble billing TMD with an appliance or Botox, make sure you also include the law on the books for your state. This is a limited list, but most states have one on the books.

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