Does Medicare Cover Temporomandibular Joint Dental Problems?
That’s a tricky question. If your TMJ disorder results from a medical condition such as arthritis, then you may be covered. Medicare often covers TMJ costs if you require surgery and/or prescription drugs. However, if the temporomandibular joint syndrome is considered a dental condition, then Medicare probably won’t cover it.
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Is TMJ Covered by Medicare?
Medicare coverage related to teeth, gums and jaw care can be confusing, especially if you’re new to the program. While Original Medicare does not cover routine dental care, such as cleanings, fillings, and checkups, Part A and Part B may help cover medically necessary care for conditions that are related to pain in your jaw.
Common TMJ disorder symptoms include:
- limited neck mobility
- neck pain
- jaw or temple discomfort
- difficulty opening your mouth
- ringing or pain in the ears
- clicking or popping sounds while opening or closing your mouth
Pain and/or restriction of movement in your jaw can be caused by a range of conditions, from arthritis to injury. If you don’t have your normal range of motion in your jaw, you may have a TMJ disorder. Your dentist or doctor may use a range of diagnostic tools, which can include an exam, x-rays, a CT scan, or an MRI. If it’s determined that you have a TMJ disorder, your treatment can vary based on the severity of your symptoms.
At-home treatments, medication, or surgery may be suggested based on your diagnosis. How can Medicare help cover your costs of care? Understanding TMJ will help you navigate what costs you may be responsible for.
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What are Temporomandibular Joint Disorders?
When you open your mouth, swallow, utter sounds, breathe and change your facial expression, you are engaging many different structures. One of the critical structures that enable these movements and functions is the temporomandibular joint (TMJ), comprised of the temporal bone, joint capsule, nerves, disc and muscle.
You have a TMJ on each side of your jaw. With your fingers positioned in front of each ear, you can feel the joint when your mouth opens. If your jaw hurts, locks or feels tender, you may have a TMJ disorder and would benefit from TMJ therapy. Symptoms include pain in the TMJ, face and ear area. You may also experience pain when you chew.
Common Temporomandibular Disorders
A TMJ disorder is one of a group of temporomandibular disorders (TMDs). The National Institute of Dental and Craniofacial Research defines three primary TMD categories:
- Joint disorders, including abnormal disc position and degenerative joint disease
- Chewing muscle disorders, such as myalgia and myofascial pain
- Headaches that accompany TMD pain
How is TMJ Treated?
According to the U.S. Department of Health and Human Services, most patients do not require aggressive treatments. Invasive treatments like surgery and implants reap potentially poor results.
- Conservative treatments include pain medication, oral devices and self-care (soft foods, ice, avoidance of specific movements and physical therapy techniques).
- Hot and cold compresses, meditation, and over-the-counter anti-inflammatory medications may be recommended by your doctor.
- The Federal Drug Administration (FDA) approved Botox for certain disorders but not TMJ disorders. Clinical studies performed to evaluate the effectiveness of Botox injections on TMJ disorders have been inconclusive.
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Does Medicare Cover TMJ Treatment?
If you are wondering how is TMJ covered by Medicare, remember that Medicare benefits are limited to medically necessary services. Original Medicare does not cover routine dental care or services involving the structures that support teeth. Pain in your TMJ may be an indication of a medical condition treated by Part A and Part B, such as rheumatoid arthritis or osteoarthritis.
If your TMJ disorder is severe enough to require surgery, Medicare Part A may help cover the costs if you’re admitted into the hospital. If you have surgery in an outpatient setting, Medicare Part B may help cover the costs.
If you require prescription medications to treat your TMJ disorder, you may get help paying through Medicare Part D. If you’re enrolled in Original Medicare and have signed up for a stand-alone Medicare Prescription Drug Plan (PDP), check your plan’s formulary, or list of covered drugs.
Is TMJ Considered a Medical or Dental Issue?
In determining if your TMJ disorder is a medical or dental matter, Medicare will review your doctor’s test results, conclusions and assessment. This may include dental X-rays, CT scans and MRIs. Your doctor may also perform an arthroscopy, which is when a small, thin tube and camera are inserted to view the joint area.
Medicare does cover specific procedures involving the jaw based on medical necessity, such as extraction prior to radiation to remove a tumor in the jaw. Another example is an inpatient oral exam as a component of a comprehensive study to prepare for renal transplant or heart valve replacement surgery. If you injured your jaw in an accident, Medicare may also cover jaw reconstruction.
Does Medicare Advantage Cover TMJ?
Medicare Advantage (MA) plans must cover the same Original Medicare benefits, but many MA plans go beyond traditional coverage. If you are an MA member, you may have a plan that includes dental coverage and prescription drugs.
Some MA plans cover over-the-counter allowances for products like ice packs and nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain caused by a TMJ disorder. An MA’s Evidence of Coverage is the document that captures all the plan’s benefits in detail. If you have questions, contact your plan directly.
Does Medicare Pay for TMJ Surgery?
Surgery is considered a last resort for treating TMJ. There is a lack of clinical studies to demonstrate the safety and efficacy of a surgical solution. You must also be willing to accept the risk that the treatment may be irreversible. Your doctor may submit a preapproval request to Medicare based on a medical need to correct an abnormality after all other approaches have failed.
Depending on the type of surgery authorized, your doctor may perform the procedure in a surgical office or outpatient facility (arthrocentesis and arthroscopy). Some procedures require general anesthesia in a hospital setting, such as an arthrotomy. When asking, “Does Medicare cover TMJ surgery?” keep in mind that the site of an authorized procedure factors into your out-of-pocket costs.
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How Medicare Part A May Help Cover TMJ Care
Part A is hospital insurance. If you have not met your Part A deductible for the hospital inpatient benefit period, you have to pay the balance before benefits kick in. The deductible amount changes every calendar year. A benefit period starts upon admission and ends after 60 consecutive days of not receiving any inpatient care.
No coinsurance is due until after 60 days in the hospital. After 60 days, you are responsible for a copayment for each day. If you have a Medicare Supplement plan, these copayments are covered in full. Some Medicare Supplement plans cover the Part A deductible as well. Your doctor’s services in the hospital are covered under Part B.
How Medicare Part B May Help Cover TMJ Care
Medically necessary services covered under Part B include your doctor’s services and outpatient care. Benefits extend to diagnostic services and treatment received as an outpatient, surgical services and supplies, and a second surgical opinion.
You are responsible for the Part B deductible in effect for the calendar year plus 20% coinsurance. If you have supplemental insurance, your Part B coinsurance and copayments are partially or fully covered, depending on the plan you have. Only legacy Medigap plans cover the Part B deductible.
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