1.                  If you have coverage with a major insurer, first go to their website or call to have a “Clinical Policy Bulletin” sent to you.  You may find these on line.  Insurers who have tried to do a good job with this will usually site the bibliography and guidelines of the American Society of Temporomandibular Joint Surgeons.  (ASTMJS.org)

 

2.                  Watch out for “lifetime maximums”.  It is not uncommon that insurers will slap a lifetime maximum on this condition.  These maximums are discriminatory as they do not do so with other orthopedic surgeries of other joints of the body.  Sometimes, HR personnel in companies have the ability to over-ride these problems, if you can do a good job of presenting your disability to them and getting them to understand that you are not about have a lot of dental work done on your teeth.  A supportive letter from your surgeon with photographs or examples of the pathology is sometimes effective in relating jaw joint surgery to other orthopedic surgery processes of the body.

 

3.                  Mixed claims:  Some insurers place coverage for a surgical supportive bite plate or splint under dental insurance, and other services under medical services.  This needs to be researched prior to treatment.

 

4.                  Medicare will cover jaw joint surgeries and many state Medicaid systems will cover the procedures.  Neither will cover the custom made bite plate that is intended to decompress the joint after surgery and during healing.

 

5.                  Out of pocket expenses:  Most of these issues deal with custom construction of a surgical splint.  Any dental tooth replacement recommendation made in order to provide the joint more tooth support protection will not be covered as well.  Splints are important in the long term.  Night wear is recommended as it is difficult for us to control issues with jaw clenching/grinding and the splint protects against excessive loads placed on an operated joint during these times.

 

6.                  What was never intended to be covered:  Any significant dental reconstruction procedure done in the name of “TMJ” management.     

 

We hope these tips help to get you started with this part of management           

                

 

Dr. William S. Kirk Jr. DDS

           

 

 

 

 

Most all Americans are frustrated with managed care and our current health care system.  This is one area that has not escaped the frustration and has its unique aspects.  This blog is intended to present some realities and educate the patient of the “uniqueness” of insurance matters and this area of health care.

 

SOME HISTORY

 

            In the 1980’s and 90’s, oral and maxillofacial surgeons in many states were politically active in their individual states and won, for their patients, legislation which prevented discrimination by insurers against many maxillofacial congenital abnormalities such as cleft lip and palate, corrective facial surgery for developmental facial/ jaw deformities, and orthopedic surgery of the jaw joint.  Imagine a child born with cleft lip and palate being denied surgery (happened all the time) due to the fact that the surgery was “cosmetic”.

 

            In the case of the jaw joint, it was successfully argued that if a jaw joint was severely affected by arthritic disease, injury, tumor etc, that if a health insurance policy viewed orthopedic surgery as a legitimate service for other joints of the body, they could not discriminate against surgical management of legitimately diagnosed orthopedic problems of the jaw joint because it was randomly diagnosed as “TMJ” heretofore understood to be a “dental problem”.

 

            Today, most individuals have health insurance provided by an employer.  Such insurance products do not have to abide by individual state laws previously passed.  They are governed by Federal law and in particular, ERISA.  Challenging ERISA would invite challenge to legal protection of unions and would create lots of problems for many Americans.  Unfortunately, funding of employee health care employees is governed by ERISA and there are many loopholes.  Employees are allowed to ignore individual state mandates if they wish to and area advised by insurers who administer their programs, as what to cover.  So, we can sometimes be back to where we were 30 years ago.  An individual can suffer from an ankylosis or fusion of another joint of the body and have no problem with having benefits for surgical replacement of the joint.  Not necessarily so for the jaw since the surgical specialists trained to perform these procedures first have dental training and entire case management process of claims reviews can be denied by entry level insurance claims review/authorization processes as “dental treatment” not covered under a medical claim process.  In our experience, patients sometimes have to endure the indignity of basic x-rays and examinations denied as “dental treatment”.  Most insurers have established clinical policy bulletins and parameters of care protocols that even they violate or do not understand.  Such are the times we live in.

 

 Dr. William S. Kirk Jr. DDS