Temporomandibular Joint Dysfunction

BULLETIN 90-3

TO: All Insurers Authorized to Write Health Insurance in Utah All Health

Services

Plans and Health Maintenance Org.

FROM: Insurance Commissioner

DATE: December 24, 1990

SUBJECT: Temporomandibular Joint Dysfunction (TMJ)

This bulletin supersedes Bulletin 85-1. The only changes from the previous

bulletin are the bulletin number, signature line and date. Everything else remains

the same.

On October 4, 1984 the Department held an hearing on Temporomandibular

Joint Dysfunction in order to collect information and take testimony concerning

the payment practices which insurers follow with respect to claims submitted for

the treatment of TMJ and to determine whether the commissioner should take

measures to achieve uniformity among insurers with respect to those payment

practices.

From testimony taken, it appears the coverage and reimbursement practices of

insurers vary greatly and some insurers are improperly denying payment of

benefits under health insurance contracts for the treatment of

Temporomandibular Joint Dysfunction.

There is no justification for routinely and uniformly excluding all treatment of TMJ

on the basis that it is "dental" on a medical policy or on the basis that it is

"medical" if the policy is a dental policy. TMJ is an imprecise diagnosis used to

categorize a variety of causes and symptoms. Since it is often difficult to

categorize the disorder as a medical or dental condition with a subsequent variety

of medical or dental treatment, this Department finds that, when it is not

specifically excluded, benefits be based on the cause of the problem and the

nature and appropriateness of the treatment, with coverage for diagnostic

procedures under either medical or dental plans paying as a medical expense

when there is a choice, since that is usually the more comprehensive benefit, and

if there is evidence of joint disease or deterioration, benefits must be allowed(c)

as medical benefits under a medical policy for any treatment that is necessary,

and if there is no

opriateness of the treatment, with coverage for diagnostic

procedures under either medical or dental plans paying as a medical expense

when there is a choice, since that is usually the more comprehensive benefit, and

if there is evidence of joint disease or deterioration, benefits must be allowed(c)

as medical benefits under a medical policy for any treatment that is necessary,

and if there is no evidence of joint disease or deterioration and there evidence of

malocclusion, benefits must be allowed as medical benefits under a dental

benefit if there is dental coverage in force and if it includes orthodontic benefits.

If express exclusion of coverage is claimed as a basis for nonpayment, the

exclusion must be made in the certificate as well as the master contract.

Documentation of the etiology of the disease and the necessity of treatment is

allowed and suggested.

Appropriate claims review personnel must be provided consistent with the benefit

claimed. All individuals within your organization responsible for administering

Bulletin

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claims must be made aware of this bulletin.

DATED this 24th day of December 1990.

Insurance Commissioner

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Bulletin

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