TN Insurance Bulletin (1988-09-01): Temporomandibular Joint Syndrome (TMJ)

c

STATE OF TENNESSEE

DEPARTMENT OF COMMERCE AND INSURANCE

500 JAMES ROBERTSON PARKWAY

NASHVILLE, TENNESSEE 37219

NED McWHERTER

GOVERNOR

ELAINE A. McREYNOLDS

COMMISSIONER

B U L L E T I N

TO:

All Health Insurers Doing Business

in Tennessee

FR:

Elaine A. McReynolds, Commissioner

~~J11

Department of Commerce and Insurance ~

RE:

Temporomandibular Joint Syndrome (TMJ)

DA:

September 1, 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

which are within the

scope

of

practice

of

dentistry

when

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.

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

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.

"/

11 B

It is the Department's position that Phase I treatment of

TMJ shall be covered

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

treatment by a dentist will not be allowed.

Coverage cannot

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