TN Insurance Bulletin (1988-05-06): Temporomandibular Joint Syndrome (TMJ)

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STATE OF TENNESSEE

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DEPARTMENT OF COMMERCE AND INSURANCE

1808 WEST END BUILDING

NASHVILLE. TENNESSEE 37219.5318

NED McWHERTER

ELAINE A. McREYNOLDS

GOVERNOR

COMMISSIONER

BULLETIN

TO:

ALL HEALTH INSURERS DOING BUSINESS

IN TENNESSEE

FR:

ELAINE A. MCREYNOLDS, COMMISSIONER ~t<~

DEPARTMENT OF COMMERCE AND INSURANCE

~

RE:

TEMPOROMANDIBULAR JOINT SYNDROME (TMJ)

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DA:

MAY 6, 1988

;

The

purpose

of

this

bulletin

is

to

announce

the

Department's

position

regarding

coverage

of

temporomandibular

joint

disorders

under

major

medical

policies.

As

you

are

aware,

TMJ

is

a

condition

involving

the

temporomandibular

joint

causing

headaches,

muscle

tenderness,

facial

pain,

and

~

other

head

and neck

pains.

Diagnosis

and

treatment

are

often

._~

multidisciplinary

in

scope.

The

question

then

arises

as

to

the

scope

of

coverage

of

TMJ

under

a

major

medical

policy

issued

in

Tennessee.

T.C.A.

Section

56-7-1002

requires

policies

issued

in

Tennessee

to

cover

surgical

procedures

or

"

other

medical

or

health

care

services

specified

in

the

policy

:i

,

which

are

within

the

scope

of

practice

of

dentistry

when

;7;

-"

performed

by a duly

licensed

dentist.

Therefore,

an accident.

and

health

policy

must

cover

treatment

of

TMJ

by

a

duly

licensed

dentist

when

such

treatment

could

also

be performed

by a physician.

;:x

-"

The

Department

has

adopted

the

American

Dental

Association

(ADA)

categorization

of

TMJ treatment

into

Phase

I

and Phase

II

treatment.

Phase

I

treatment

includes

diagnosis

and

management

of

systems.

Treatment

may

include

soft

diet,

medications,

thermal

agents,

temporary

splints,

and

voluntary

self-

disengagement

of

the

teeth

be performed

by a physician.

;:x

-"

The

Department

has

adopted

the

American

Dental

Association

(ADA)

categorization

of

TMJ treatment

into

Phase

I

and Phase

II

treatment.

Phase

I

treatment

includes

diagnosis

and

management

of

systems.

Treatment

may

include

soft

diet,

medications,

thermal

agents,

temporary

splints,

and

voluntary

self-

disengagement

of

the

teeth.

Phase

II

treatment

occurs

once

symptoms

have

subsided

and

the

patient

has been maintained

through

appliances

in

a stable

pain-free

condition

for

from

3-6

months.

Such

treatment

may

include

alteration

of

the

occlusion,

which

may be accomplished

~

through

occlusal

adjustment

of

the

teeth,

restorative

~

treatment,

prosthodontic

treatment,

orthodontic

treatment.

or

'

surgery.

,

-

r

It

is

the

Depar~ment's

position

t':\a:

Phase

I

trea:ment

.,f

~

TMJ shall

be cover~d

by accident

and health

policies.

In

addition,

surgery,

although

part

of

Phase

II

treatment,

should

also

be covered

by accident

and health

policies

when surgical

procedures

could

also

be performed

by a physician.

Policy

filings

will

be

reviewed

in

light.

of

this

announced

position.

Accordingly,

any

exclusion

of

TMJ in

a

major

medical

policy

will

not

be allowed.

Any

exclusion

of

r~~'

treatment

by a dentist

will

not

be allowed.

Coverage

cannot

;~A

be limited

to

surgical

means

only.

The Department

will

allow

~:~~

an

exclusion

for

orthodontics

or

treatment

to

the

teeth

or

~~

gums,

however,

the

Department

does

not

consider

Phase

I

treatment

to

be

treatment

to

the

teeth

or

gums.

Phase

I

treatment

of

the

temporomandibular

joint

may,

under

Phase

I

treatment,

be

accomplished

in

some

instances

through

the

application

of

devices

to

the

teeth

or

gums and would

not

be

excluded

under

an

exclusion

for

treatment

to

the

teeth

or

gums.

EAM/cmf

~.

,

.

\

~

iI

~~

tI;l

s

not

consider

Phase

I

treatment

to

be

treatment

to

the

teeth

or

gums.

Phase

I

treatment

of

the

temporomandibular

joint

may,

under

Phase

I

treatment,

be

accomplished

in

some

instances

through

the

application

of

devices

to

the

teeth

or

gums and would

not

be

excluded

under

an

exclusion

for

treatment

to

the

teeth

or

gums.

EAM/cmf

~.

,

.

\

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iI

~~

tI;l

.

1

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PAGE 2

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