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making state mandate TMJ coverage

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There is an interesting article by Cigna about TMJ coverage. They are nice enough to cover TMJ care if medical necessity is determined, or if state mandates it.

How does one go about mandating state to make ins companies cover TMJ care?
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First Helper sunflower09
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replied September 12th, 2008
Supporter
CIGNA HealthCare covers arthroscopy for TMJ disorder as medically necessary when BOTH of
the following criteria are met:

Pain or significant hypomobility persists despite at least six months of scientifically recognized
noninvasive therapies such as pharmacologic pain control, physical therapy and the use of intraoral
appliances.
• Clinical examination and diagnostic imaging indicate the presence of joint pathology that requires
internal structural modification
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replied September 12th, 2008
Supporter
My Insurance
My current, Illinois State Comprehensive Health Insurance,
ICHIP, totally excludes coverage for TMJ.

What can I do?
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replied September 15th, 2008
Supporter
OK,. there was a lady here on the board who posted a while ago, I really hope she can provide some insight about the methods she used. She said she went against some commission, and did not give up - the state finally mandated TMJ coverage.
Illinois is pro consumer state, governor has many plans in regards to insurance, so he will be my next office to call. I wish more people would take up this cause. Contacting the Senate might help too.
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replied December 4th, 2010
Insurance TMJ
I am having difficulty figuring out where to begin also. I live in Missouri. I have had TMJ for a very long time. It continues to get worse. I am in so much pain at times and we have established the only way is surgery. I have tried everything else. I have been eating a soft food diet for almost 2 years! However, there is no coverage and the surgery would be 15,000 upfront out of my own pocket. I would have to take out a loan. I think this is ridiculous! Recently, my DR wrote a letter of medical necessity and insurance CO just say..."NO COVERAGE!" I am trying my best to get through the days and I need help! Where can we start to get this resolved...this is a real problem for people...it exists and people should not be left with NO TMJ COVERAGE when this is their(and my)final option! If anyone has suggestions where I can begin....it would be very helpful!
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replied December 22nd, 2010
Insurance continues to deny, even though I have a few Doctors notes stating it is medically necessary for me to have this surgery and I have exhausted all other avenues. I continue to take strong anti-inflams. and strong pain meds as needed, which is more often than I would like. It seems as if the insurance CO. doesn't have an issue keeping me on all that stuff, but I seriously cannot live on that the rest of my life, nor can I stand the pain anymore. It is ashame that this will have to come from my own pocket. I have student loans to be paid off and haven't landed that School Counseling job yet...I just keep praying something positive will happen. 12,000+ is a lot of money for an average person to have to come up with : (
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replied December 28th, 2010
I live in California and was diagnosed with condylar resportion - it has been very costly just dealing with day to day living. The medical insurance doesn't want to cover stuff because they say it is dental (TMJ) related....then the dental insurance says no - it is medically related and that they should cover. Everytime they want a new scan or xray to monitor my jaw joint - it becomes a fight over who will pay...which usually ends up being me. Nobody understands how costly jaw related issues are until they go through it. But I couldn't agree more - there needs to be insurance for it - you wouldn't say - sorry legs and arms aren't covered...why the jaw??
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replied December 28th, 2010
I could not agree more with you. The sad thing is this is really painful and we are just expected to live with this or cough up the money and I have come to the end. I can't eat and my ligaments are tearing everyday, which is causing the sharp pains shooting through my mouth...but who needs a jaw right? I would like to see something done about this, but I haven't a clue where to begin. My Dr. called the medical board directly pleading the severity of my case for coverage and they said oh we agree she certainly needs it and it is necessary, however it is an exclusion so we aren't paying for it....that is very nice of them isn't it. Where to begin?
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replied December 29th, 2010
My surgeon did the same thing - he went to the Board and tried to get the splint at least covered - and they said no. I was very grateful that he tried - but I had to shell out $800 bucks for a special splint. I have no clue where to begin. Short of just coming up with a facebook page to start to get the word out - it is little - but I don't know how to get people to listen to this problem.
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replied December 29th, 2010
I even thought about contacting a news station...may sound lame, but just stationg to them how the insurance companies cover just about everything, and even when Doctor's deem this medically necessary for us they still deny coverage. They simply state this as an exclusion from benefits. I even have contacted a state senator...I believe I will be waiting awhile for that response, but I think this is a huge issue for a lot of people and we are expected to take care of the expences as if it is elective...I am sorry I dod not elect to have TMJ or the severity of the pain and issues that I am having along with it? They act as if I am having some type of cosemetic surgery. Facebook may be a place to begin. I do like that idea!
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replied January 4th, 2011
Insurance Coverage
Hi Swearigen,

I'm a tmj sufferer in Indiana and they don't have the best laws in terms of insurance covering treatment. I found a site that listed several states that prohibit the discrimination of tmj coverage whether the services are rendered by a physician or dentist and California appeared to be one of those states. Have you found it difficult to get all of your treatment covered? This is interesting to hear.
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replied January 5th, 2011
I am in Missouri. I have 2 insurance companies and they both EXCLUDE TMJ coverage! I am in need of a surgery due to dislocations, torn ligaments, etc. The Dr. appealed to the insurance companies with a letter and then a phone call to the medical board. They all said that I was def in need of the surgery by the looks of the MRI's and other test results and Dr.'s notes and I had exhausted all other options. The ins. co said that I needed it bad, but they were not going to pay for it. I think this is a HUGE topic for many people that has to be addressed. There are way to many of us out there suffering with this, not able to eat normal, in pain and the insurance companies dictate how we live our lives and what is best for us? How is that right? I am so sick of this. I am scheduled for surgery and it makes me ill the amt of money it will cost me. I feel I have no other option. my ligaments keep tearing and there is nothing left of my jaw on my left side and complete dislocation on both left and right. I know how people with this feel and wish we all could find a way to get this problem heard and fixed! What website did you get that info on??? Sorry for long posts, I am just angry about all of this...let me know good to hear from poeple who are going through the same thing : )
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replied January 5th, 2011
Sunflower09 I can totally understand your frustration and I just can't believe that a joint that is probably the most important in the body, isn't covered by most insurance. It just feels like it is a never ending battle and I wonder how people got the laws changed in certain states. I am not a surgical candidate yet, but I am certainly preparing for the day where I might be. I am really considering leaving Indiana to go to Minnesota or a state that has legislation in place regarding tmj coverage. Its just sad when you have to relocate to get the healthcare you need and I don't even know if that will help. I do know that some of the people I talk to on my other tmj support site get their surgeries covered with no problems. It all depends on what state you are in from what I see.
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replied January 5th, 2011
There is something seriously wrong with the laws. They consider mine an elective surgery...as if I were having cosmetic surgery. Last I checked, I did not elect myself to have TMJ. The funniest thing is that everyone wants their money upfront for the surgery...where my sis-n-law had breast augmentation and she could pay those off in monthly installments, lol there is something very wrong with this picture.

I am very sorry to hear about your situation. I am interested to see how the laws were changed in other states also. Relocating somewhere for a medical problem should not have to happen. I tried Emailing a Senator regarding this issue and have yet to hear back. I may try a Representative too. I think they should know this is going on...but bottome line is they probably do not care, unless a large group sends stuff or the word gets out somehow. I enjoyed hearing from you, and I appreciate your responses! They help me out to keep on this : )
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replied January 5th, 2011
I can not believe they have the nerve to determine that tmj treatment is cosmetic. Thats just another tactic for insurance companies to deny paying. They have no problem collecting their money out of our pay checks, but then turn to deny a valid and painful chronic condition. Its hard enough living in pain but to have to fight just to get help is ridiculous and only causes more stress. Sometimes I wonder where am I living. Healthcare should be a basic right and I hate that tmj sufferers are left to suffer in pain. I agree that most politicians don't seem to care. I think the only thing that would catch their attention would be large groups like you mentioned or if they personally could witness how debilitating this condition can be. I'm a single mother and it is so hard to come up with the money upfront for treatment. I have had to drop $1600 before just for a splint so I could open my mouth. Its so hard to get ahead because my savings is always getting drained because of my regular appts with my orthodontist. I can only imagine what would happen to me and my daughter if I ever need surgery and I'm still in this state. Scary thought. You hang in there and know that you aren't alone. Another good place for support is the tmjsurgeryfamily site.
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replied January 5th, 2011
Thank you for the information! I appreciate it. I agree..this is not cosmetic and we are suffering. They deny and we are put with more added stress. We all have TMJ expenses, we all have other bills that have to be paid and many other things that need to be taken care of (especially when life throws you a curve ball and you have an emergency to deal with). They just expect us to throw down money for splints, mouthguards, meds, physical therapy, surgeries, oh and the Dr apts., etc like it grows on trees! Again, thank you for the info and hang in there too! It is good talking with you!
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Users who thank sunflower09 for this post: appraiser 

replied January 15th, 2011
Im in the very same boat, located in Missouri and at the point of either moving to try and get better coverage, or paying out of pocket for bi-lateral joint replacements Sad

Wish there was a better way!!
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replied January 27th, 2011
TMJ
I've been suffering with TMJ for 3 years now. My insurance says it is a cosmetic issue. How can it be cosmetic when noone can see the damage??? Yes, some states have mandated coverage for TMJ, but the insurance company has to be based in that state. I have tried to fight it to no avail. They have no problem paying for the vicodin, trazodone, depakote, oxycodin, etc. etc...Now I am going to counseling to deal with the pain and depression from this everyday frustration, they have no problem paying for that either. Don't you think it would be cheaper to cover the problem instead of the effects of the problem???? I am in constant pain and can't get a good nights sleep, I have severe headaches and at time earaches and neck pain that make me want to curl up and just die.......How is it that we can treat other humans in such a way that we are left to suffer or self medicate to help deal with such huge issues that noone can help or even care to hear about. I bet if the President had TMJ someone would fight for it to be covered, too bad I am just a normal, broke citizen..........
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replied February 19th, 2011
I have to say how ridiculous insurance companies are! I had to pay to have surgery, and was denied an appeal that was sent in and called in by my Dr. I had to pay out of pocket, but felt I was left with no hope and no choice due to the tremendous pain I was experiencing.

When my Dr. finally got into my mouth...he was shocked! My original MRI taken 8months prior showed the dislocations on both sides(left always the painful one). So, within that 8months here is what happened...

My disc had a hole in it and my jaw bone had become lodged and stuck within that hole. My ligaments were
torn and so tangled up within that hole too as well as some of my facial nerves. My hour surgery becam closer to 3.

I find this interesting...cosmetic, how in the world is that cosmetic and how can someone live like that and like everyother person suffering from this pain. My entire disc had to come out, along with some jaw bone and all the ligaments and nerves had to be carefully dealt with. I have nerve damage, which will take time to heal, but I have no clue how I was supposed to live like that...that explains all of the awful shooting pain and why I could not open my mouth at all very far with out the intense pain.

I feel for everyone who is in my position. I have no clue how I will pay for this surgery, but it was a necessary surgery NOT COSMETIC as the insurace companies like to call it for us!
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replied May 26th, 2015
Anyone Have Advice Years Later?
Hi all,

My wife's been suffering from TMJ for years now and we've elected to just pay out of pocket. But now she is requiring surgery and an artificial jaw hinge - its become medically necessary if she wants to eat and talk without pain. Given that its going to cost 10's of thousands of dollars in cost I'm researching what I can do about getting my insurance company to at least pay for some/all of it. We've done the first MRI and they started the denied policy with that. I know this is an old thread but I thought I'd see if anyone made any headway in their efforts, what they did, and what resources are out there for me.
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