question about reading my insurance benefits

[TechBoyJK]

I was put on hold for a while and never got through to representative and I'm at work so I can't be on the phone. I'm really curious about this so maybe atot can help me make sure I'm reading something clear...

I have TMJ, which is a jaw joint disorder. My case is that my tmj disc (the disc between your skull and mandible) is locked out of place so as I open and close my jaw it grinds in between the joint, causing my jaw to lock very often. Sometimes I have to punch my jaw out of the lock. Not fun. To fix, a slit needs to be cut in front of my ear, and the disc needs to placed back in its right spot and the jaw muscles treated for any damage. It's a pricey surgery considering an MRI is needed.

Anyways, my dental doesn't cover it, but I think my medical does. I was reading my benefits on under non-covered and I read this

for dental treatment, regardless of origin or cause, except as specified elsewhere in this Certificate. "Dental treatment" includes but is not limited to: Preventitive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums, including but not limited

-extraction, restoration and replacement of teeth
-medical or surgical treatments of dental conditions
-services to improve dental clinical outcomes

And under In Network Covered Services for "Temporomandibular or Craniomandibular Joint Disorder and Craniomandibular Jaw Disorder

-Services based on setting where Covered Services are received.

Under "temporomandibular or Craniomandibular Joint Disorder" Section

See the Schedule of Benefits for any applicable Deductible, Coinsurance, Copayment, and Benefit Limitation Information.

Benefits are provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muslce) disorders. They are covered if provided within Our guidelines.


So I guess this means I probably covered but it depends on where I have the surgery?

 

[Savij]

Sounds like it's covered to me. Probably the best thing to do would be to follow your regular procedures as far as getting a referral from your doctor and making sure that the specialist/surgeon/hospital/clinic are in your insurance network.

*not any sort of expert

 

[TechBoyJK]

Originally posted by: Savij
Sounds like it's covered to me. Probably the best thing to do would be to follow your regular procedures as far as getting a referral from your doctor and making sure that the specialist/surgeon/hospital/clinic are in your insurance network.

*not any sort of expert

thanks. I just wanted to make sure I wasn't missing something. And I did that. I had gone to my dentist first and he diagnosed it as TMJ (he is a TMJ specialist) and referred me to a surgeon (same surgeon who did my wisdom teeth). He is In Network listed as a specialist for the surgery I need.

Thank God. I thought I was on my own for a while because as of right now there are huge fights with the insurance companies about TMJ. Health insurance companies try and say its a dental thing, and Dental says the opposite. People with health and dental insurance all over the country were being left without coverage on something that keeps them from being able to eat and open their mouth, etc.. and finally some congressman called BS on it and pushed legislation stating its a medical thing. Seeing how my insurance company has a special section on TMJ, thats probably the case and now they cover it. Between the MRI, pre-op, op, and post-op procedures, I'm looking at a 10K bill to get my jaw fixed.

 

[MixMasterTang]

For stuff like that you just need to get the insurance to pre-authorize the surgery/procedure. Always do your due dilligence to make sure they are going to cover it even if it is something that they state they cover.