Is there a logical explanation for why no health coverage will pay for treatment pertaining to the jaw?

January 15, 2010 11:32 PM

What is the logic behind exclusion for treatment for TMJ by nearly all insurance companies and Medicare?

I would like to understand why TMJ is "not covered" and/or excluded by insurance companies and Medicare. Any claims for treatment of TMJ are always rejected out-of-hand. Other disorders in joints (such as knee, wrist, ankle, etc) are recognized as legitimate pertaining to treatment and payment for treatment.

Why do insurance companies regard the joint of the jaw as "baseless" for problems? Isn't it logical that any and all joints in the human body are susceptible to deterioration/malfunction?

I am simply asking in an effort to determine the logic behind the across the board denial of any claims for TMJ by insurance companies and Medicare.

posted by naplesyellow to health & fitness (6 answers total)

I don't really know but some googling turned up stuff like this:


Insurance companies generally do not cover the cost of treating TMJ-related claims for two reasons. First, there is too much controversy about the causes as well as treatments of the problem. Second, there is little scientific validation of TMJ therapies. In fact, some treatments appear to cause new TMJ problems or exacerbate existing ones.

posted by RustyBrooks at 11:40 PM on January 15, 2010

I can't answer your question as to why TMJ is excluded, but I do know that there are all sorts of different ways that your doctor's billing clerk can code your visit to make sure that it is within the types of medical issues that insurance will cover. Don't be afraid to have a frank discussion with your doctor, especially if he/she has a billing clerk on site (as opposed to farming the task out to an outside agency) and ask if they can code your visits and treatment in other ways (for instance, instead of citing TMJ specifically, they can code it as indeterminate jaw pain, or headaches, or inflamation). If your doctor is uncooperative, try someone else.
posted by amyms at 11:58 PM on January 15, 2010 [1 favorite]

A friend of mine had a lengthy episode of the healthcare and dental powers-that-be passing the buck on whether his prolonged jaw thing was due to "TMJ" or complications with wisdom teeth. I lost touch with the guy, but the last I heard, he was rather dependent on Vicodin.

Maybe it's in part due to that "iffyness" of the symptoms being medical- or dental-related.

After writing this, I just read RustyBrooks's link and it seems to agree with my friend's plight
posted by The Potate at 12:04 AM on January 16, 2010

It's not covered because that way they don't have to pay for it. Seriously, you can look for "legitimate" reasons, but it all boils down to - as long as they can get away with not paying for it, they won't.
posted by fairywench at 5:36 AM on January 16, 2010 [1 favorite]

Anything that happens anywhere near your mouth and jaw (including TMJ) will get classified as "dental" if at all possible...which means almost no medical plan will have to cover it.

/insert screed here about the inanity of the lack of parity for essential dental care given its impact on general health
posted by availablelight at 8:41 AM on January 16, 2010 [1 favorite]

I have been in the limbo of TMJ for decades. Doctors "don't" treat it because it has to do with dentition, and dentists "don't" treat it because it's a structural problem.

I have been fortunate enough to find 2 dentists who DID treat my TMJ. One in the military spent months with bite plates and night guards, and actually "straightened" my jaw by aligning the jaws and retraining the muscles.

Because a true 'cure' would involve both maxillofacial and oral dental surgery, finding a team that would be covered by most insurance companies is nearly impossible. Unless it hampers your ability to eat and speak without excruciating pain, it would be on your own dime....
posted by Jinx of the 2nd Law at 7:39 PM on January 16, 2010