#79 “Why Insurance Companies Don’t Want to Cover TMD/TMJ”

The second most common question I hear patients ask at the time of their consultation is “Why doesn’t my medical insurance cover your device and protocol?”  Sometimes I give a short answer and sometimes I give the more comprehensive response.  The short answer is, “Because they don’t want to.” The more comprehensive answer usually takes about 5 minutes.

The short answer also includes that insurance companies are in the business to make money. No matter what their slick ads and public relations messages say, they are not there to help you.  Their purpose is to limit the fees charged by hospitals, doctors, and other health care providers as much as possible to make a profit for themselves.  For the full story regarding insurance companies, I’ll refer you to a book by Dr. Robert Pearl, ex CEO of Kaiser Permanente Health System, entitled “Mistreated, Why We Think We’re Getting Good Health Care- and Why We’re Usually Wrong”

The more comprehensive answer I share with the patient covers four (4) facts and one story.

Fact 1:  The consensus about TMD/TMJ among dentists, physicians and patients derived from experience over the past 70 years is that “Nothing Works”  Half the dentists don’t want anything to do with TMD/TMJ because they know nothing works, and the other 49% make a “night guard” to protect the teeth and tell the patients it will solve the problem, knowing it won’t, and hope the patient doesn’t come back.  Although the people who run insurance companies are in the business to make a profit, they are not dumb.  They know that if they start to pay for a service that is predictably unsuccessful, they will enter a losing battle financially.

Fact 2: TMD/TMJ is a Rabbit Hole that has no end.  Insurance companies have experienced years of various theories and treatments by providers that cannot show valid success for their patients.

Fact 3:  Insurance companies only want to cover a diagnosis that has an agreed-on standard of care and can be validated by independent university statistical studies.  Paying for treatment that is not the standard of care and does not have independent validated studies increases their liability to the patient and sometimes the government.

Fact 4:  Insurance companies are aware of the small subset of dentists who try to make the treatment of TMD/TMJ as complicated and drawn out as possible in order to game the system and apply convoluted medical codes to get around the fact that there is no medical CPT code to treat TMD/TMJ non-surgically.  I call this sub-set of dentists “TMJ Guru’s” who use “Smoke and Mirrors” and call it treatment.  Some of these TMJ Guru’s even run courses on how to game the system as to appear to be treating a different diagnosis when the problem is actually TMD/TMJ. There are CPT codes that cover TMD/TMJ surgically and insurance companies have used every excuse possible to deny surgical coverage for years.  I am very familiar with that ploy having treated  TMD/TMJ surgically for the first 36 years of my 50 year career as an Oral and Maxillofacial Surgeon.

And finally, I tell the patient the story our 4 year battle with Blue Cross/Blue Shield of Tennessee attempting to convince them that our university validated, patented, FDA cleared device and protocol with over 4,000 successfully completed cases should be recommended for a medical CPT code and insurance coverage to benefit patients.

Eventually a formal meeting with BC/BS executives, their chief attorney, and chief medical officer, was scheduled.  All the data showing our discoveries about the real cause of TMD/TMJ and how this joint works and reacts like any other joint in the body was brought out.  The result of this meeting requesting  coverage was firmly, and flatly denied with no appeal possible.

The answer for, “Why don’t medical insurance companies cover TMD/TMJ? is simple.  “They don’t want to”.

On the flip side of this limitation, our team at TMJ Services of Brentwood has worked out several methods to make our service as affordable as possible, giving the patient several financial alternatives.

You can see more information about who we are and what we do at www.tmjservicesofbrentwood.com.