Why Isn't Insurance Covering Your TMJD and Jaw Pain?

After completing my round of physical therapy for my TMJ Disorder I was hit with the bill: over $2000 dollars. Pause. Why the hell am I paying $2000 if I was already paying copays. Shouldn’t my insurance be covering the rest?

After sitting on the phone with the claims manager, it turns out they charge the insurance company differently than those who are uninsured. So they resent the bill. “Only” 600 dollars. Not including what I already paid for copays. 

Now, this wasn’t the first time I’ve heard of TMJ not being covered by insurance. But it was the first time I felt the bite. And it made me realize that others with TMD can have it a lot worse than me.

So why is insurance not covering TMJ Disorders?

Well this question goes deep, so listen up.

First off, let’s be clear. Insurance companies are pretty much never going to cover TMJ treatments unless forced to by the state. Specifically, unless forbidden by the state, insurance companies can exclude TMJ treatment from their plan. 

There is some nuance to this as well. Policies can exclude past a certain dollar amount. Or they can pick which treatments to cover, like surgical procedures only. But even these nuances are often determined by the state.

In general though, only these 20 states require insurance to cover TMJ. 

Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Maryland, Minnesota, Mississippi, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, Texas, Virginia, Vermont, Washington State, Wisconsin, West Virginia

If you live in these states, I would recommend calling your insurance carrier to learn how they cover it (I know it’s annoying) because remember it can vary treatment to treatment.

So why are the mandates so slow to adopt in the US?

Here’s the short answer: because it’s a fairly new concept to think of TMJ as its own condition. Historically, TMJ Disorder has floated in the void between dentists and physicians. It wasn’t believed to be a Dental specialty until a couple years ago, and to this day isn’t covered by things like dental insurance because, well, it doesn’t have to do with your teeth. But physicians often didn’t treat TMDs because they believed it to be a dental phenomenon (grinding and bite misalignment).

In reality, TMJ Disorders really are a complex mix of dental, myofascial, and orthopedic practices. And for lack of effort in research, there has been no scientific consensus about TMJ diagnosis or treatment. 

Many treatments like Botox still aren’t FDA approved for TMJ Disorders. Other treatments like splints have had a history of making things worse. And Physical Therapy can only do so much without proper diagnostic methods backing it. This is why government legislation is slow moving around adding TMJ as a mandatory condition for coverage by insurance companies.

This isn’t to say that the right treatment for you doesn’t exist out there - but it means that there is not enough systemic understanding to guarantee your doctor will be able to provide that treatment. It’s up to you to go read blogs, research papers, join communities and forums like reddit and Facebook groups. Before wasting your own money on treatments that might not work, do everything in your own power to find and treat the underlying conditions at home.

One last note. When your doctor prescribes you something for your TMJ that may not be insured, you should have a discussion about this. Your doctor has a lot more decision making power in this area than you might think. For example they might code the treatment for a headache or inflammation or something else that may end up being covered.  

If you have any questions, feel free to contact us or write it in a comment!

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