Health Insurance Questions for TMJ

CherylL24

See if your specialist will submit this to your health insurance under "Myofascial Pain Dysfunction" which is a medical disorder.

Tests such as tomograms will inevitably be submitted to your dental insurance, as they are not medical in nature.

Hope this helps. Good luck.

TMJ82

I am not an insurance specialist, but here's my story.
I have United Helathcare Choice PPO and they do not cover anything billed as TMJ. My treatment so far costed me $2400 ($400 - TMJ diagnostics and $2000 orthotic/splint + 4 months of adjustments). I was not offered TENS and such, but I have a home TENS/EMS unit and it does not do any good. Splint seems to help, though.

I do not have much money either, but I needed relief and thus payed out of pocket (GE money 18 months no interest). If you decide to fight with insurance company, make sure your doctor is in network. If he/she is out of network, you may be required to pay the whole amount upfront and sometimes they bill insurance company more than self-pay patients for the same treatment. For instance, if I decided to use my insurance, they would have billed $4400 (not $2400) and I would have to pay this amount upfront and then wait months for reimbursement from my insurance, which I am sure would not have been 100%. So basically, I still would have gotten stuck with the hefty bill plus months of waiting for the check and headaches from dealing with insurance company.
I hope it helps and good luck with your treatment!

rocckyd

The billing question really all comes down to why you have tmj and how the dr reports it. Mine is due to an autoimmune issue so I've only had to pay copays. My insurance has covered a bilateral TJR and PT for a year. I'm not in that gray area of medical/dental that so many people fall into.

I would hope your dr can find a way to code it that would provide the most coverage. Do you have a copy of what your policy covers? Each insurance company has so many plans, it's hard to really give advice. I have Anthem but my plan is often not the same as somebody else's Anthem plan. It depends on what pay your employer provides.

I do know that many people struggle with the insurance issue. While I don't know if I'm lucky that mine is an autoimmune issue, I am lucky in the fact that I don't have to battle for coverage.

I hope you can find some way for insurance to cover it. I would call your carrier and then talk to the person at the drs office who deals with coding/insurance. Good luck....

Shirlett

I agree with Rockkyd, it is ALL ABOUT how it is submitted to the insurance company. MOST will try to say it is "Cosmetic" but if it is filed as a medical condition most will pay. If you can, find a "teaching hospital" and try to get in with them, that way a lot of the cost is absorbed via the interns learning from you, plus the teaching hospitals tend to have better equiptment. I hope you get some answers!
Take Care!
Shirlett

Baptong

I just want to say you guys have been extremely helpful and I will take all your sage advice into account when I start treatment next week.

As for what my policy covers, they sent me a packet but it is pretty much general information. There isn't any type of info that explains the criteria for exclusion from coverage. I really do hope my insurance company will cover at least half of this.

Also I should probably mention I am currently not employed and on the individual Copay Select plan.

If anybody else has advice please feel free to let me know. Thanks and hope to hear from you guys

woolfnstein

I have had several insurances and they would not pay for a dentist to perform any treatments related to TMJ. Maybe it is because I had dental insurance and medical insurance. Even when my pre-work was submitted under medical, they would approve, then after the surgery or treatment deny. When insurance companies deny many dentist/doctor offices put the burden of proof on you to make the insurane claim is approved. I was stuck with a bad debt on my credit because I could not pay more than $50 a month on a $2,000 bill.

My last insurance was United same as others have mentioned in this thread. They waited four months after my surgery to deny it. Thankfully, my doctor and his staff had the documentation and fully supported the need for surgery. United paid the doctor, hospital, etc. all within a month of receiving the information from my doctor. Without a job now, I would not be able to pay the $250,000 to cover all bills.

Good luck.

Baptong

@Woolfstein - Thanks for the information and I love your username

TMJ82

I think, your best bet would be to get the procedure codes from your doctor's office and call insurance company directly if they will cover those codes specifically and if so, what %. Also, check if your doctor is in network (if this applies to you).

Also, if you're not on the group plan, they can deny your TMJ coverage as a pre-existing, couldn't they? Be sure to ask about that as well.

Dealing with insurance companies can be a nightmare, especially when you desperately need relief. I wish you the smoothest road possible and please do let us know how it goes!

Baptong

Thanks for the information and I will keep you guys updated. Also, because I'm on an individual plan my coverage can actually be denied as pre-existing?! Pleassssssssssse do no let this happen.......

Will keep you guys updated.

ninamarc

I don't know how your insurance plan is set up, but here we got dental plan and health plan in the private insurance plan. So some stuff is not paid for if ordered by dentist. If it is ordered by a doctor/GP/physician, then the treatment or MRI may be covered 75% and etc.
It really depends on if it is "health issue" or "dental issue". Dental issue still tends to be lesser matter. If you get the treatment plans from a GP or physician or even jaw surgeon, you may get more coverage as true health insurance.
We all know TMJ is hard and dental matter is not minor, but it is how the insurance co. deals with it.

I would go to my GP to set up these plans. Or ask the dentist refers you to a physician for it.

Good luck,
Nina

tmjat16

CherylLynn24 I saw on a different post that your son has tmj and I was wondering if he has had any success with treating it. Im 16 and have had bad tmj problems for about 6 months now. Please let me know if you have had any good results and how? I wasnt sure how else to ask you so i am posting on here. Thnx

woolfnstein

Baptong,

I have not seen an update from you on the 'journey of insurance'. Being in this type of pain adds to the stress you incur in receiving the treatment you deserve. Many people on the TMJ board have paid a lot of money out of pocket because of the insurance battle. After my surgery to move my lower mandibular jaw forward I found that my dentist did not have any type of documented proof for why I needed the surgery. This was the first time a doctor dumped his file in my lap and said it was up to me to fight the insurance company. The lady in my dentist office was so rude and forget about helping me understand what medical coding was.

Long story short, I had to pay for everything. This caused me to go into deep depression with major anxiety, I did feel worthy and continued to endure pain.

Sorry, do not mean to dump my nightmare on you but the other responses you received in the thread from our group should help you have a better customer experience. At least you know you have rights and the doctor/insurance company have a responsibility to you.

Please update us on your adventure, I wish you well.

woolfie

Baptong

Well, my insurance company has screwed me over.

I submitted the two claims in the beginning of September and was reimbursed for one for one of them by late September. The one I was reimbursed for was a couple thousand while the other one was for several hundred and was in pending. Well, I thought I was in the clear so I went and spent the reimbursed money on several bills that needed to be paid. After about a week I get two letters in the mail from my insurance company's S.I.U.(Special Investigation Unit) requesting medical records from my doctors. So I got them and sent them in. Several days later I call the person in charge of my case and asked if everything was fine. Well she told me they will require the reimbursed money back because my plan does not cover non-surgical TMJ treatment......

Seriously, I am at a loss right now because I can't get that money to them because I already spent it on bills. Is there ANYTHING I can do? I can borrow some money from friends but I don't think I can come up with the exact amount. Do you think I can get the insurance company to negotiate to whatever I can scrounge up?

Sorry for the long post guys but darn, I didn't think I would get so badly screwed over......... Any help will be appreciated.

-Baptong-