#114 Why is TMD/TMJ Not Covered by Insurance?

Before answering this question, I need to first define Insurance.  According to the dictionary, “Insurance is a practice or arrangement by which a company or government agency provides a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a premium”.   

There is a huge difference between medical insurance and dental insurance.  Medical insurance contracts with the person insured to pay for illness according to the specifications of the insurance policy.  The policy specifies the conditions upon which the illness is covered and often comes into conflict with what the patient thinks is covered.  The frequent denial of medical claims is a testament to the difference between what the insurance company feels is covered and the patient’s expectations.  With enough attention by the patient or the patients health care provider, there are instances when the patient actually receives more payment for services that the premiums paid.  Automobile insurance is a good example of insurance.  If your monthly premium is $100 you are likely to receive much more in compensation if you have an accident and total your car which may be worth $60,000.  Like car insurance, medical insurance sometimes compensates their insured much more than the premiums when the insured has a catastrophic disease or injury. 

Dental insurance is not insurance as defined by the dictionary.  Therefore, companies that call themselves dental insurance companies use ‘confusion of words” to mislead the public.  Dental policies are actually dental plans which simply charge a premium each year and return only a specified portion of the premium for services by a dental service provider and keep a portion of the premium for themselves as administrative costs.  On Average, dental plans keep about a third of the premiums paid for their administrative services.  The only similarity between medical insurance and dental plans, (“insurance”) is that dental plans also make it their business to deny a significant number of claims.  Dental plans never re-imburse more than the individual or the individuals employer pays in premiums. 

Now that you understand why dental plans are not insurance policies, I can address why neither dental plans nor medical insurance cover TMD/TMJ. 

The TMJ is just one of many joints in the body, but the only joint treated by dentists rather than medical professionals.  Medical doctors wanted no part of treating the TMJ because it is part of the chewing mechanism and associated with 32 teeth for which medical doctors have no training.  But TMD/TMJ is actually a medical problem.  When I used to do surgery for TMD/TMJ it was always covered by medical insurance unless the policy excluded TMJ/TMJ specifically.  When dentists try to treat TMD/TMJ with methods other than surgery, medical insurance policies state they don’t cover dental services.  There is no CPT code for the non-surgical treatment of TMD/TMJ, therefore no medical coverage.  Dental plans won’t pay for a valid medical treatment. When dental plans are asked to cover non-surgical medical coverage for TMD/TMJ they say they do not cover medical services. Many medical insurers consider TMJ treatment too dental-focused for medical insurance, while dental insurers consider it too medical for dental insurance, leaving patients stuck in a “medical-dental divide” that hinders care.  

Temporomandibular Joint Disorder is a very common disease with 45 % of women and 5-10% of men afflicted with one or more of the disparate symptoms of this devastating disease. The medical insurance companies and the dental plans are happy to tell patients paying their premiums that someone else is responsible to cover these health care services, as long as it’s not them. 

Unfortunately, this is the current situation regarding health care re-imbursement for TMD/TMJ. 

The Urbanek Device and Protocol is patented and cleared by the FDA as a medical device.  The device and protocol affect only the Temporomandibular joint (TMJ).  It does not treat the teeth are any associated dental structures. 

Fortunately,  the 95% success rate of the Urbanek Device and Protocol is far more valuable than the value of insurance coverage.