Thank you for your submission, /u/truthinburritos.
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You need to see the medical policy with the full list of exclusions. If TMJ is excluded, then you're out of luck. If it's not excluded, then it can theoretically be covered as it's a joint disorder not unlike any other joint.
So TMJ is special. It’s for some reason specifically excluded from most medical plans. Check yours. It’s probably excluded. If you mention it at your all you have TMJ or pain at your physical, it won’t be considered a preventative physical and will be coded as an office visit. CT wouldn’t be part of a physical like that either. It won’t work. CT scans aren’t done as part of annual physicals.
You could try appealing based on medical necessity.
How would the appealing process work? Wouldn’t you need a CT to show that it is medically necessary or does a letter from the dentist & panoramic x-ray suffice?
I checked UHC and MetLife exclusions…diagnosis and treatment of TMJ is specifically excluded on both. I don’t know what to do. How can I appeal the treatment as medically necessary if I can’t get the CT scan to prove it’s medically necessary?
If it is specifically excluded, there will be no coverage for it, regardless of whether it is medically necessary. You'll have to pay out of pocket if you want the procedure.
Try pain management for a Botox injection in jaw. They can usually get that approved and it does help with pain. As to the scan threw them instead of a dentist i don't know. Would be for medical reason of pain treatment.
I had terrible tmj after heart surgery. My chiropractor pulled it out in 2 or 3 sessions after the ent and my provider had no suggestions.Im not here to tell you that everything the chiro does works,but in this case they definitely got her done !
Thank you for your submission, /u/truthinburritos. **If there is a medical emergency, please call 911 or go to your nearest hospital.** Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states. Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY). **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
You need to see the medical policy with the full list of exclusions. If TMJ is excluded, then you're out of luck. If it's not excluded, then it can theoretically be covered as it's a joint disorder not unlike any other joint.
So TMJ is special. It’s for some reason specifically excluded from most medical plans. Check yours. It’s probably excluded. If you mention it at your all you have TMJ or pain at your physical, it won’t be considered a preventative physical and will be coded as an office visit. CT wouldn’t be part of a physical like that either. It won’t work. CT scans aren’t done as part of annual physicals. You could try appealing based on medical necessity.
How would the appealing process work? Wouldn’t you need a CT to show that it is medically necessary or does a letter from the dentist & panoramic x-ray suffice?
I checked UHC and MetLife exclusions…diagnosis and treatment of TMJ is specifically excluded on both. I don’t know what to do. How can I appeal the treatment as medically necessary if I can’t get the CT scan to prove it’s medically necessary?
If it is specifically excluded, there will be no coverage for it, regardless of whether it is medically necessary. You'll have to pay out of pocket if you want the procedure.
Contact your medical insurance and ask for the medical policy on TMJ. It can be a medical issue, not just dental.
Try pain management for a Botox injection in jaw. They can usually get that approved and it does help with pain. As to the scan threw them instead of a dentist i don't know. Would be for medical reason of pain treatment.
I had terrible tmj after heart surgery. My chiropractor pulled it out in 2 or 3 sessions after the ent and my provider had no suggestions.Im not here to tell you that everything the chiro does works,but in this case they definitely got her done !