TMJ and insurance
January 22, 2015 11:13 AM Subscribe
Asking for a friend:
"I have TMJ & I'm looking for new insurance. I've noticed that Health Choice Insurance doesn't exclude TMJ, but you have to be authorized for it. The company seems small, and to partner with a handful of clinics. Does anyone have experience with this company, or with a different company who would cover an occlusional splint specifically made for the treatment of TMJ?"
We're in Arizona, and she's in pain right now. Any dental insurance wants her to wait a year if they even cover it at all (and pay for half after waiting in pain for a year), and most health insurances seem to exclude TMJ. Thanks in advance for the help!
We're in Arizona, and she's in pain right now. Any dental insurance wants her to wait a year if they even cover it at all (and pay for half after waiting in pain for a year), and most health insurances seem to exclude TMJ. Thanks in advance for the help!
I've never had dental insurance cover TMJ.
I've also never been successful getting my medical insurance to cover it either although the couple hundred bucks have always been worth the out of pocket expense for the splint.
posted by radioamy at 11:26 AM on January 22, 2015
I've also never been successful getting my medical insurance to cover it either although the couple hundred bucks have always been worth the out of pocket expense for the splint.
posted by radioamy at 11:26 AM on January 22, 2015
Response by poster: more details from friend:
"On the health insurance marketplace, the health choice is the only one that doesn't specifically exclude TMJ. My current one excludes, and this is actually the first plan I've seen that doesn't.
The entire procedure cost $5k last time I had it done, and it worked. I've had the same splint since 2006. My teeth have spread, though, and wearing it gives me intense headaches, plus it makes my teeth move a bit (slightly loose) because the splint pulls on them. The treatment is a process of relaxing muscles that have atrophied over the course of several visits so as to get a measurement that is impossible to get without doing those visits. Last time was 2-3x per week for 2 weeks. Then make the splint using these measurements. It's been durable, but it's time for a new one. I've never had my insurance (health or dental) cover it."
posted by Weeping_angel at 12:25 PM on January 22, 2015
"On the health insurance marketplace, the health choice is the only one that doesn't specifically exclude TMJ. My current one excludes, and this is actually the first plan I've seen that doesn't.
The entire procedure cost $5k last time I had it done, and it worked. I've had the same splint since 2006. My teeth have spread, though, and wearing it gives me intense headaches, plus it makes my teeth move a bit (slightly loose) because the splint pulls on them. The treatment is a process of relaxing muscles that have atrophied over the course of several visits so as to get a measurement that is impossible to get without doing those visits. Last time was 2-3x per week for 2 weeks. Then make the splint using these measurements. It's been durable, but it's time for a new one. I've never had my insurance (health or dental) cover it."
posted by Weeping_angel at 12:25 PM on January 22, 2015
I truly don't wish to be rude, but I am wearing a nightguard (aka occlusal splint) right now and mine cost $500 because I overpaid. I would urge your friend to determine what made the experience in 2006 so expensive (literally ten times more expensive than mine) because perhaps she doesn't have to pay that much this time?
Second, because I'm sure she would appreciate an answer that talks about the specific health insurance company, I looked at the Evidence of Coverage for Health Choice Insurance and their page on TMJ is not particularly positive.
What I'm seeing under Gold Coverage is this language:
"Covered benefits are payable for services and supplies which are necessary to treat TMJ disorder which is a result of:
1. An accident
2. Trauma
3. A congenital defect
4. A developmental defect
5. A pathology
Benefits include diagnosis and treatment of TMJ that is recognized by the medical or dental profession as effective and appropriate treatment for TMJ, including intra-oral splints that stabilize the jaw joint. Prior Authorization is required."
Frankly, that sounds like if the TMJ is not the result of an accident or defect, then you can ask for authorization all you want but you aren't going to get it. I'd strongly urge your friend to call Health Choice, or stop by one of the Healthcare.gov centers if in Maricopa County, and confirm.
posted by librarylis at 9:18 PM on January 22, 2015
Second, because I'm sure she would appreciate an answer that talks about the specific health insurance company, I looked at the Evidence of Coverage for Health Choice Insurance and their page on TMJ is not particularly positive.
What I'm seeing under Gold Coverage is this language:
"Covered benefits are payable for services and supplies which are necessary to treat TMJ disorder which is a result of:
1. An accident
2. Trauma
3. A congenital defect
4. A developmental defect
5. A pathology
Benefits include diagnosis and treatment of TMJ that is recognized by the medical or dental profession as effective and appropriate treatment for TMJ, including intra-oral splints that stabilize the jaw joint. Prior Authorization is required."
Frankly, that sounds like if the TMJ is not the result of an accident or defect, then you can ask for authorization all you want but you aren't going to get it. I'd strongly urge your friend to call Health Choice, or stop by one of the Healthcare.gov centers if in Maricopa County, and confirm.
posted by librarylis at 9:18 PM on January 22, 2015
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posted by brainmouse at 11:16 AM on January 22, 2015