205 W. Randolph Suite 1800 • Chicago, IL 60606
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 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
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.
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
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
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