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 selfdisengagement 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