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Treatment Costs and Insurance Coverage

The dollar cost can't make my life any worse than it is now.
—a 35-year-old public relations director

They say they will cover it if I'm hospitalized!
—a 29-year-old pregnant woman

It's difficult to talk about treatment costs for TMJ, because they vary so much from patient to patient. The costs are determined by the amount of time spent in Phase I treatment and the kind of procedures used in Phase II. Phase I treatment is basically the same for everyone, yet some patients are pain-free in a matter of weeks, while other patients are in Phase I treatment for many months.

Let's consider a general range of costs for an average patient. If a patient is in Phase I treatment for four months and has an equilibration as the Phase II definitive treatment, the cost will probably run from $2,000 to $3,000. If a patient requires extensive reconstructive work as part of Phase II, the cost can be much much higher. There is no way around stating that TMJ treatment can be costly.

INSURANCE COVERAGE

Insurance coverage for TMJ is variable. People with standard health insurance coverage can have coverage can have an appendectomy and expect the insurance company to cover this procedure. It is considered standard and therefore will not be challenged. TMJ treatment is handled differently for many reasons, some having to do with the nature of the disorder.

TMJ is a dentally based orthopedic disorder with medical manifestations. The basic source of the problem might be the teeth, but the symptoms mimic many medical disorders and complaints. Numerous branches of the healing arts are called upon to treat headaches, neck, shoulder, and back pain. Even bruxing is often viewed not as a dental problem, but as a psychological one.

Many patients believe that their dental insurance will be an appropriate source of coverage for TMJ treatment. However, this is seldom true for Phase I treatment. Dental insurance usually covers dental surgical procedures, such as fillings and root canals. Dental policies often limit the amount paid per year per family member. They may exclude orthodontia or other procedures having to do with occlusal changes (changes in the way the teeth fit together when the mouth closes).

Because TMJ is on the borderline between medical and dental concerns, some medical insurers don't want to deal with it. To them, it sounds like dental procedures and, therefore, outside the realm of medical coverage.

Because of all these dilemmas, insurance coverage for TMJ can be sporadic and unpredictable. Sometimes medical insurance covers Phase I treatment, and then dental insurance picks up portions of Phase II treatment.

MEDICAL POLICIES

It makes sense for medical insurance, which usually covers orthopedic procedures, to cover Phase I treatment, basically because the splint is an orthopedic appliance. It allows the jaw to move and function normally. Also, treatment in Phase I is eliminating symptoms that have medical implications.

To date, many medical insurance companies pay benefits for TMJ therapy. However, more and more insurance companies are adding TMJ treatment to their exclusion riders. Because diagnosis of TMJ is becoming more common, companies are making these decisions in order to keep total costs down. Some policies do offer TMJ treatment inclusion as a special option.

If you are considering treatment for TMJ, examine your policy and see whether the condition is specifically mentioned. If it is excluded, you will not be covered for non-surgical treatment for TMJ. Most exclusion riders state that surgical intervention into the joint will be covered. Since only 2 to 5 percent of the patients seeking treatment for the condition need surgery, this has serious implications. It encourages people to seek the kind of treatment their policies cover, rather than what is most appropriate and safe.

The kinds of coverage people receive from their medical policies vary, too. Some policies cover the splint but not the needle puncture. Others cover the needle puncture but not the splint. This is handled on a case-by-case basis and is still unpredictable.

THE INSURANCE DILEMMA

The insurance dilemma is one that needs to be resolved in order to provide coverage for this common and often debilitating disorder. Not covering TMJ makes little sense, considering that the costs of investigation into the cause of headaches often are covered. Some patients whose insurance companies have paid thousands and thousands of dollars for tests, examinations, and treatments have never gotten better. Now that an effective treatment is available for the cause of so much pain, it seems ridiculous not to cover it. In the long run, much money could be saved.

When people are looking at insurance options, they should consider which kind of policy will have the best options for TMJ.

Sometimes it means paying an extra premium to have the treatment included. For other people it means choosing an insurance plan rather than joining an HMO or a capitation plan. A capitation plan may be fine if the group of dentists being contracted with includes a dentist who can do successful TMJ treatment. Since few HMO's include dentistry, coverage for TMJ treatment, except surgery, is unavailable.

Many patients end up paying large portions of the treatment costs themselves. Often they do this because they see the treatment as an investment in their future. Numerous patients have been able to live fuller and more productive lives after they had TMJ treatment. Pain takes an enormous toll, and few people who live in chronic pain are able to manage highly successful careers. But once they become pain-free and can live normally, they realize their personal potentials. Patients have told me that in the long run the treatment much more than paid for itself through advancement in business or a career that became possible when TMJ was resolved. In fact most have said that it was the best investment they had ever made.

In the coming years, there will be many changes in insurance- company policy regarding TMJ treatment. This is bound to happen as more and more people seek help and raise questions about coverage. Changes will also occur because the condition is becoming more widely known and recognized in the health care community. But at this time do not assume that treatment will be covered. Choose your insurance plan cautiously.