Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    As a member, you may or may not have a benefit for coverage of Temporomandibular Joint (TMJ) problems. Please consult your coverage documents for clarification.

2)    When diagnosis and treatment of TMJ problems are covered services, these services require preauthorization.

3)    Some plans cover only surgical treatments for TMJ, such as joint replacement or reconstruction.  Such plans would not cover non-surgical treatments such as therapy or mouth guards.  Non-surgical treatments (self-help techniques and medical treatments) need to have been tried and failed before surgical treatments can be authorized.  If your physician or dentist is recommending treatment for TMJ problems, please make sure that you understand what kind of treatment is being recommended.

4)    Dental work such as orthodontics, crowns, implants, inlays, on-lays, or bridgework or dentures, is not covered under the medical benefit even if done primarily for treatment of TMJ conditions. 

TMJ problems may or may not be covered under plans administered by QualChoice. This includes both treatment and diagnostic studies.  When services for diagnosis and treatment of TMJ problems are covered, all such services require preauthorization.  Please consult your patient’s coverage documents or call customer service for further clarification.

The diagnosis and assessment of TMJ may include such tests as x-rays, MRI studies, arthrograms and the creation of models of the jaws so that the treating physician (or dentist) can determine the dynamics of chewing.

The treatment of TMJ may range from simple splints and bite blocks to significant surgical rearrangements of the jaws. Some plans provide payment for splints but not for surgery.  Some plans provide coverage only for surgical treatment of TMJ.

Coverage for TMJ surgery may be more restricted than coverage for other dental-related problems, such as:

Coverage for care of traumatic injuries to sound natural teeth. Some services are covered during such treatment that would not be covered under any other circumstance (such as in the case of TMJ problems).

Coverage for surgery to produce normal anatomic alignment in cases of cleft palate. Here again, some services are covered that would not be covered under any other circumstance (such as in the case of TMJ problems).

Codes Used In This BI:

Addendum.

1.     Effective 01/01/17: Added x-ray code and description.

2.     Effective 12/01/2017: Added step care requirements to try/fail self-help measures before medical treatments and medical treatments before surgical treatments.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.