Health Policy - New York State

Our Web Site

« RFI on a "point of entry" for long term care | Main | Mathew Holt on liability trends »

April 07, 2004

Comments

Jan Mabbett


Temporomandibular Joint Disease (TMJD):
Discrimination of an Anatomic Part – Your Jaw Joints -90% Women Having this Disorder

The citizens of New York State are being denied consideration for proper insurance coverage for temporomandibular joint diseases and disorders.

TMJ refers to a collection of medical conditions affecting the
temporomandibular joint and/or the muscles of mastication ( chewing muscles), as well as related tissue components. The TMJ’s are the two tiny joints in the front of the ears that attach the lower jaw to the skull.

Not only do the jaw joints rotate as other ball-and- socket
Joints, they move down and forward. These joints allow us to perform such functions as opening and closing the mouth, chewing, swallowing, breathing, kissing, and talking. Problems that can occur with the temporomandibular joint are arthritis, trauma, tumors, tearing or dislocation of the disk. TMJ diseases/disorders run the gamut from a clicking or popping jaw and mild discomfort to complete jaw dysfunction and severe intractable muscle and nerve pain.

Fifteen to 20 years ago, when medicine and dentistry first began to realize that people were having head and neck pain related to jaw joints, there was a lot of confusion as to whether this was a medical or dental condition. However, this is a medical condition treated by the dental profession and other allied health groups. Insured’s are routinely provided benefits for conditions affecting all other body parts, only benefits for conditions related to the bone and joints of the jaw are specifically excluded under major medical and dental policies. There should be no discrimination based on anatomic parts and discipline of the provider for treatment for this disorder. According to the National
Institute of Health, over 10 million Americans suffer from TMJ
disease/disorders, and conservative treatment is recommended, surgery is a last resort. Both males and females have TMJ disease/ disorder; however 85 to 90% of those getting TMJ disorder are woman.

Twenty other states have mandated insurance coverage for this ailment. It is our position that every New York citizen should have the right to equal medical benefits for treatment of all muscles, bones, and joints in the body with no exclusion for the jaw joints. Conservative treatment of TMJ disease / disorder would include various therapies including physical therapy, craniosacral therapy, biofeedback, scenar therapy and orthopedic devices created by dentists and treatment by dentists having specialization in TMJ treatments. When this bill is passed it would allow the patient to have this joint treated medically and paid for by medical insurance just as any other joint dysfunction in the body is currently. Currently, in the Senate and Assembly there are bills S113 and A1175 to amend the insurance law in relation to health insurance coverage for diagnostic testing and treatment of TMJ disorder/disease (a Craniofacial jaw joint disorder). These bills have been deadlocked in the
insurance committees of both the Senate and Assembly for 4 years now.

Individuals that suffer with TMJD find that diagnosis and treatment fall into a gray area between medical and dental insurance coverage.The proposed legislation would resolve this impasse in favor of regarding TMJD as a disorder of the JOINT, categorizing it as medical in nature and covered by medical insurance whether treatment is rendered by a dentist, doctor or other health care professional. This is the only joint in the human body that is discriminated against by insurance companies. Additionally, this is a life-Sustaining Joint,
meaning that one cannot eat, speak or breathe without utilizing this joint.

In 2003 we met with various Assembly members on the insurance committee and a majority of them have indicated their support in favor of this bill. At the suggestion of Senator Seward chairmen of the Senate Insurance Committee, we have also met twice in 2004 with insurance reps and their medical directors to see if there could be some kind of agreement to voluntarily cover TMJD without having it mandated into law. The insurance
medical directors were provided with a lot of documentation, studies and able to talk with the professionals treating TMJ at those meetings. The meetings were unsuccessful, as the insurance companies to date have not voluntarily offered to cover TMJ disorders. However, as a result of those
meetings,the bill has been amended to mirror the language that is contained in other states that cover TMJ and is indicated as an act to amend the insurance law in relation to health insurance coverage for craniofacial disorders.

The following are some of the points that were covered in the March 7, 2005 meeting in Albany with the Senators on the insurance committee in the Senate:

a. In North Dakota they did an analysis of health insurance
mandates and it was found that the cost to cover TMJD came to $.37 per policy per individual, which is a minimal cost compared to what patients pay out of pocket for treatment.


b. SHARE Corporation, an HMO in the state of Minnesota conducted their own study on costs incurred to them in providing conservative treatment for TMJD once legislation was mandated. Gretchen M. Eckes, Director, writes, "In the two years we have treated 338% more patients, with a cost reduction of 13.8%. There have been zero member complaints about either the guidelines or the TMJ specialists.
Surgical intervention has been reduced from 10.5% of all cases to 2.5%, certainly a benefit to the patient and the insurance company." This HMO found that they saved money after the law was amended in that state to cover craniofacial disorders and or TMJD conservative treatment. Currently in New York State we are pushing people into surgery for TMJ problems because that is the only treatment that insurance companies will sometimes pay for. Only 5% of the patients with TMJ actually need or require surgery. Surgery is expensive. Thus, it is more cost effective to allow for conservative treatment than to pay for surgery. Even the NIH recommends that surgery be a last resort, NOT the first option in treating TMJD.

Based on these findings, changing the insurance law to cover TMJD treatments would benefit not only the patient, but the insurance companies as well. The cost per policy to cover TMJD is minimal and even business would benefit as it would decrease employee absenteeism if conservative treatments were employed as opposed to surgical intervention. TMJ patients would win also from early diagnosis an proper treatment which would save them much pain and suffering. It would be a
win-win situation for all.

c.The United States Navy provides a post-graduate two year Masters Degree Program for military in the field of TMD and Orofacial Pain. The U.S.military recognizes this field as a specialty and subsequently provides insurance coverage to military personnel for these conditions. As such, this large component of the U.S. federal government does not exclude this part of the body from medical insurance coverage.

d. In New York State the only health care professional that can legally insert an orthopaedic appliance in a person's mouth are dentists. This results from the fact that medical doctors do not possess the expertise to craft these orthotics. Since there is no other place in the body that supports this kind of tmjd orthotic, the task of treating a person with a TMJ orthotic has been given to dentists. Medical doctors can only manage the disease with drugs and are not taught in medical college how to treat TMJ disease.

5. The number of people having TMJD and needing treatment is 1 out of 40 people. New York State has approximately 20 million people(constituents). So roughly you are talking about a half a million people that are in need of insurance coverage for TMJD in New York State.

6. The American Academy of Orofacial Pain (AAOP)have developed and published well documented parameters of care for management of craniofacial disorders, including TMJ that include calculated protocol for evaluation, diagnosis, treatment , assessment and prognosis. The International Classification of Diseases, 9th Revision, Clinical Modification ( IDC-9-CM) applies to all craniofacial diseases and disorders , therefore medical codes for billing purposes already exist for clinicians to bill insurance companies for treatments. These guidelines
along with documentation, studies, articles were presented to various legislators as well as to the medical directors of the insurance companies.

7. The courts have ruled each time when patients have filed ligatation against their insurance companies for lack of coverage for diagnosis and treatment of TMJ that this is a medical joint disorder. Citizens of New York should not have to rely on the court systems to litigate against insurance companies for lack of medical coverage in relation to TMJ disorder. This is currently the only option for forcing an insurance company to pay for diagnosis and treatment of TMJ disorder. Many citizens
with this disorder can not afford treatment let alone mounting an
expensive litigation suit against their insurance company for failure to cover TMJ disorders. Also from a personal stand point the External Appeals Process is not an effective route to obtain insurance coverage for diagnosis and treatment of TMJD, as I personally tried that avenue and was denied the external appeals process based on TMJD is an exclusion in my insurance policy.

Below are some results of some of the court cases :
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 is not an effective exclusio 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
whicb was originally denied by tbe 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 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 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.

8.Insurance coverage for TMD and Orofacial Pain is not, in it's truest sense, a mandate. It is in effect prohibiting the exclusion of a selected body part. It prohibits a medical policy from discriminating against the jaws and craniofacial structures.

9. We have contacted every member of the Assembly and the Senate and the responses we have received to date are that they will support this measure if it comes to the floor for a vote.


We, along with Dr. Crandall , Dr. Kull, Dr. Gelb, and Lisa Gilberti, PT and our fellow TMJD patients in New York State, urge you to help bringthis legislation into enactment by writing your assembly member and Senator to ask them to support these bills and to pass them into law to protect yourself and others from being denied benefits for this disorder in the future. Currently because the bill is sitting in the insurance committees still after 4 years it would help to write or email the Chairman of both the Assembly Insurance Committee and the Senate Insurance Committee and ask them to but this bill on their respective agendas of those committees and move them forward and state your support for this proposed legislation.Addresses are below of :

Chairmen of Insurance Committees:

Senator James Seward Room
917 Legislative Office Building
Albany, NY 12247
(518) 455-3131
seward@senate.state.ny.us

Assemblymen Alexander B. Pete Grannis
LOB 712
Albany, NY 12248
518-455-5676
grannis@ assembly.state.ny.us


Senator Joseph Bruno, Majority Leader
Room 909 Legislative Office Building
Albany, NY 12247
(518) 455-3191
bruno@senate.state.ny.us

Assemblymen Sheldon Silver, Speaker
LOB 932
Albany, NY 12248
518-455-3791
speaker@assembly.state.ny.us

For information on TMJD and the proposed New York State TMJ Health Insurance Bill, please visit our online petition site:
http://www.smbs.buffalo.edu/wcmpi/nystmjbill/petition.html

There is a private TMJ support listserv established for TMJD patients who would like to be in contact with other TMJD patients. For further information, contact Susan Burkard, schwarzkopf@yahoo.com OR Jan Mabbett, jmabbett@yahoo.com









Krystal Marshall

I am wondering if there are any current case law for medicaid recipients that suffer from, DMJD. Federal foremost, but state would be great to.

The comments to this entry are closed.