Does Medicare Cover TMJ Treatment?

Temporomandibular joint (TMJ) disorders can cause jaw pain and limited movement and sometimes make it painful to eat or talk. Fortunately, most cases of TMJ disorder can be treated conservatively. However, you may require prescription medications or surgery if your symptoms are severe or persistent. 

It's important to know how you'll fund your care if you need TMJ treatment. So, does Medicare cover TMJ treatment?

Does Medicare Cover TMJ Treatment?

Whether Medicare covers TMJ treatment depends on the treatment you require. Many people can treat TMJ successfully at home by relaxing the jaw muscles and taking over-the-counter pain relief to reduce discomfort. Original Medicare does not cover the costs of medication, with or without a prescription. 

You may be able to secure coverage for TMJ treatment medications through a Medicare Part D plan. Medicare Part D plans are available through private insurers, and each insurer has a formulary listing the drugs it is prepared to fund. You'll need to check your provider's formulary to determine if the drugs you need are eligible for coverage. 

Medicare Part A may cover TMJ surgery if you are treated as an inpatient or Part B if you have an outpatient procedure. However, Medicare only covers surgical costs when the treatment is deemed medically necessary and when you've exhausted all the more conservative treatment avenues. Therefore, your doctor will need to demonstrate that you've tried every available non-invasive option, and that it hasn't worked, before Medicare will consider funding your operation. 

Does Medicare Advantage Cover TMJ Treatment?

You might be entitled to TMJ treatment coverage if you purchased a Medicare Advantage policy through a private insurer. Medicare Advantage Plans cover the same services and treatments as Original Medicare, but they may also cover a wider range of treatments according to the provider.

Many Medicare Advantage Plans include Part D drug coverage which may cover the costs of medications used to treat TMJ disorders. You should check your insurer's formulary — a list of covered drugs — to check that it covers the medication you need. 

Like Original Medicare, Medicare Advantage Plans generally only cover treatment that is medically necessary and is the least expensive and invasive option. Therefore, you will usually only qualify for funding for surgery if you've tried non-invasive options and they haven't worked. 

Is TMJ Treatment Covered Under Medical or Dental Insurance?

Some people find it difficult to secure Medicare coverage for TMJ treatment because the condition occupies a gray area between medicine and dentistry. Medicare doesn't cover dental treatment unless it is carried out when you're already hospitalized, in which case it may be covered by Part A. Medicare may also fund your hospital care for emergency or major dental surgery if it requires inpatient treatment but not for the costs of the procedure itself. Some Medicare Advantage plans include dental coverage.

Therefore, beneficiaries with TMJ should seek support and guidance from their doctors when claiming for TMJ treatment through Medicare. It is important that your doctor highlights the medical nature of your condition and that there is no underlying dental cause. 

Does Medicare Cover TMJ Surgery Recovery?

Most people can recover from TMJ surgery at home. However, if you need to recover in the hospital, your post-operative care may be covered by Medicare Part A. Beneficiaries with Part D coverage may be eligible for assistance paying for any medication they need while recovering, even if the procedure itself wasn't funded through Medicare. 

What Are TMJ Disorders and How Are They Treated?

The letters TMJ stand for the temporomandibular joint, which is the joint that attaches your jaw to the skull. TMJ disorders cause pain in and around the joint and may lead to joint mobility issues such as locking. TMJ disorders have various causes, including arthritis, trauma and bruxism (teeth grinding). 

Most cases of TMJ disorders resolve over time with conservative treatment, which could include over-the-counter pain relief, relaxation exercises and hot or cold packs. Physical therapy and prescription painkillers, antidepressants and muscle relaxants can also help reduce the pain and mobility issues associated with TMJ disorders. 

In more severe cases, corticosteroid injections or surgery may be required. Invasive treatments are generally considered a last resort and are usually only considered if the condition doesn't resolve with conservative protocols.