I am so fed up. i have TMJ and arthritis in my jaw on both sides. Went to a neuromuscular dentist who told me he could help with this. This, of course, comes at a high price. $6500.00. I do not have dental insurance and so he tried to get my medical to pay for the work by calling it everything from facial pain to arthritis to temporal tendonitis, to name a few. The lousy company would only possibly cover about $1000.00 of it and only maybe, (meaning no). They would not budge, the office there called and even broke everything down to medical codes and nothing, nada. I am in alot of pain, daily. Eating is a huge problem, sleeping, what's that? I go side to side all night with the pain in my ears and the surrounding area. I have been to an ENT and know its' all TMJ related. It is so frustrating that we pay sooo much a month for this lousy insurance and get nothing in return.

Sorry for complaining, I am just so mad about needing treatment and can't get it from the people who are supposed to help.

((((BIG HUGS)))) so sorry you are suffering...hope you find some relief soon.I know what you mean about health insurance....i am very lucky and thankful to have good coverage....if i'm sick,i can go to the dr. and get a prescription...but...to be honest,it's not my Dr. that decides the tests i get done,the treatments i receive or what prescriptions i get,it's my insurance because i only get what they cover....

That is so wrong!!! I have it too but not as bad as you.
Will the doc. work with you on payments?
((hugs))

enough....is there a dentist office close to you that has a sliding-scale fee??

Thanks everyone. Yes, I can get a no interest loan from the dentist but for $6500 I can't do payments on that right now. As soon as I find a full time job again, then I'm in. It'll all work out eventually. In the meantime, hot compresses, soft foods and wine!!!!!!!

(((Enough))),


Your situation makes me so angry! IMO, it's simply wrong for health insurance companies to not cover major dental procedures. Our mouths and jaws are part of our body. Why exclude them? Ugh! I wonder if your insurance would cover the procedure if a general surgeon rather than a dentist performed the surgery? Have you tried contacting your insurance company's grievance department? I goggled "TMJ surgery covered by insurance" and found this information: (I am in no way affiliated with the attorney who owns the website.)

I hope you feel better soon. Take care. jem

TMJ - Law Information Help
TMJ is a Medical Disorder:
In Masella v. Blue Cross & Blue Shield of Connecticut (United States Court of Appeals for the Second Circuit, 1991), plaintiff was diagnosed in 1985 as suffering from temporo. mandibular joint dysfunction or TMJ, a painful disorder of the jaw joint. As a result, she received non-surgical treatment, including biofeedback and an orthotic, an appliance that fit on the plaintiff's teeth and was intended to reposition part of her jaw joint. When the plaintiff submitted the claims to her insurer for payment, they were rejected. The basis for the insurer's declining the claims was that the treatment was dental in nature (rather than medical) and was thus excluded from coverage under the relevant health insurance policies. The plaintiff then commenced an action seeking to recover the denied benefits. After the trial court found in favor of the plaintiff, the insurer appealed. The United States Court of Appeals for the Second Circuit affirmed, ruling that TMJ was a medical, rather than a dental disorder and was covered under the relevant policies.

Like the district court, we find persuasive the views of Masella's experts that Masella's treatment for TMJ principally related to the jaw joint rather than the teeth. We recognize that neither Sorrentino, who treated Masella, nor Mark, another dentist specializing in oral and maxillofacial surgery, is necessarily entirely impartial on the question of whether Blue Cross should be required to reimburse claimants for the treatment of TMJ under the terms of policies like Masella's containing "dental" exclusions. However, their explanations of the nature and treatment of the condition known as TMJ, which are essentially unchallenged by Blue Cross, consistently and clearly describe the focus of a TMJ disorder and its treatment as a joint that happens to be connected to the teeth, not the teeth themselves. The Connecticut Society of Oral and MaxilIofacial Surgeons (the MaxiIlofacial Surgeons), appearing as amicus curiae, also describe TMJ and its treatment as focused on a disorder of the jaw rather than of the teeth, and refer us to a substantial number of state court insurance cases so holding.(Citations omitted.)
RESULTS OF COURT CASES FOR HEAD, NECK AND TMJ DISORDERS
1 - Ponder v. Blue Cross of Southern California, 193: Rptr. 632, Cal App. 1983: The health insurance policy had an exclusion denying payment for dental care including "treatment for or prevention of temporomandibular joint syndrome" The Appellate Court held that this was not an effective exclusion.

2 - Jowers v. Nationwide No. CV 85-, 2 December 1986 Terrolyn Jowers recovered $703.00 medical expenses, $175.75 Bad Faith Penalties, $5,000 attorney's fees and $1,000,000 punitive damages for her TMJ treatment which was originally denied by the insurance company.

3 - Goss v. Medical Service of the District of Columbia et al, District of Columbia Court of Appeals, No. 81 - 1276, 13 June 1983 Blue Cross/Blue Shield's position was that putting crowns on the teeth is considered dentistry. The Patient's position was that the crowns were medically necessary to correct a malpositioned jaw. Court results: "There was no need for the crown and bridge work independent of the TMJ. In fact the crowns were directly related to, and required by, the medical condition of Mrs. Goss' jaw. The treatment was not required to, and did not treat any condition of Mrs. Goss' teeth or tooth relationship as Mrs. Goss' teeth were used to support the devices required to stabilize the position of her jaw." Blue Cross Blue Shield was ordered to pay for the treatment.

4 - Robinett v Metropolitan Life Insurance Company, 404 So. 2d 1344 1981 (Louisiana): "The appliance used to treat the patients condition was not an end in itself but rather was intended to relieve pain from her mandibular joint rather than to correct her dental problems. Reasonable minds would not inevitably conclude that, as a matter of law, procedures performed on her were "dental services" excluded from coverage under health policy."

Enough,
You have me on a mission this morning! I don't know what state your are in, but check out the following:
(Note: In my last posting, I used the term "general surgeon" without thinking! I believe they just do basic simple surgeries? woops! Also, read "insurance considerations" for an explanation of why insurance companies exclude TMJ surgery.) jem


http://www.tmj.org/insurance3.asp


TMJ Diseases & Disorders - Insurance

• Will My Insurance Company Cover TMJ Diseases?
• Insurance Considerations.
• TMJ Treatment & Third Party Insurance Coverage.

TMJ Treatment & Third Party Insurance Coverage
Minnesota, in 1987, became the first state to adopt legislation requiring health insurance policies issued within the state to include coverage for the diagnosis and treatment of temporomandibular (TMD) joint disorders and craniomandibular (CMD) disorders on the same basis as other joint disorders. At present, 20 states have laws, regulations, or directives to that effect, although the specific requirements vary. Most are based on the theory of prohibiting discrimination. The laws do not have retroactive effect.

((((big hugs)))) hope you find some relief soon....

Thanks for all your research. Of course I live in NJ, where nobody does anything legally. I called Blue Cross myself as did the neuro muscular dentist i went to as well and we both spent a lot of time and talked to several people and sent letters and they still would only cover $1000.00 of the total $6500. I even tried an attorney, but nothing. For now, until i find a job I will eat soft food and use hot compresses.

I really appreciate all your work and will fight for this, it is wrong not to cover it. Maybe another letter is due.