Will My Insurance Pay for This?

Our providers are Fee for Service/Out of Network by necessity. Historically, medical insurance excludes coverage for TMJ/Pain treatment and limits access to specific appliances for Obstructive Sleep Apnea. Obstructive Sleep Apnea is a medical condition treated with a dental device. Because it is a medical condition, only medical insurance will provide coverage. This is subject to your annual medical insurance deductible. If you have met your deductible, they will generally cover more expenses. If you have not, your payment will apply to your deductible for other services you may need this year.

Great news: your care at our office is not limited because we do not contract with insurance companies. You and the provider determine what is best for you versus the insurance company dictating your care.

We do not accept insurance because we care about you too much. If we did, our practice would not be in existence to serve the 5,000+ patients we've treated. Medical insurance chooses to not reasonably participate in paying for conservative treatment for TMD, Craniofacial Pain and Dental Sleep Medicine.

So, why do you not work with insurance?

The short answer is because we cannot deliver the quality of care you deserve with the constraints that insurance companies force upon the doctor and patient. The limitations they place make it impossible to deliver the services we provide. Contracting does not allow patients to choose what they want to do. This is precisely why the major medical establishments locally do not participate in the care of these issues, as they cannot get reasonably reimbursed for it to be practical.

Here are some examples of the constraints currently present:

Medical insurance does not approve treatment of mild Obstructive Sleep Apnea (OSA) without a prior heart attack, stroke, depression, and comorbid conditions. We believe it’s best to treat the breathing disorders prior to a patient developing the chronic diseases that they contribute to.
They will not approve treatment of OSA with oral appliance if patient has signs or symptoms of TMD.
We often recommend a 3D CBCT (Cone Beam CT scan) to help with our diagnostic evaluation of the anatomy and in January 2022 the CPT code 76102 was eliminated thus cannot be billed to medical insurance.

Every provider across the country often utilizes “orthotics” or appliances for treatment of TMD, bruxism, etc. In July 2015 the CPT code S8262 for TMJ Orthotic Appliances was eliminated, thus it cannot be billed to medical insurance.

Medicare

Medicare does not cover TMJ/TMD treatment, thus we cannot contract or be a preferred provider. Insurance companies do not determine the standard of care for TMJ disorders and Sleep Breathing Disorders. Physicians and Dentists determine the standard of care. The American Dental Association has some good guidelines for care, but the ADA is not a credentialing body. There are two credentialing bodies concerning Craniofacial/Orofacial/TMD issues: the American Board of Craniofacial Pain and the American Board of Orofacial Pain.

Recently the ADA has approved Orofacial Pain as a specialty and the credentialing board is the ABOP. Thus, Federal Courts have allowed Board Certified individuals to recognize their specialties to the public; hopefully, this will translate into better insurance coverage in the future. What’s fascinating is that most insurance plans that cover TMJ surgery require non-surgical procedures first; the same procedures that they don’t pay for.

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