Medical Insurance on July 1st 2015 dropped the coding for TMJ orthotic appliances. That means that there is now no medical insurance coverage for the primary treatment of non-surgical TMJ disorders (Appliance Therapy). Medical insurance also does not have coding for the CBCT (Cone Beam CT scan) which is considered the best hard tissue x-ray diagnostic tool for TMJ disorders. Medical insurance usually has benefits for the TMJ MRI which is useful in some situations. Sleep Apnea appliances continue to be a covered expense by many medical insurance plans if the proper protocols are followed.
Dental insurance plans sometimes offer coverage for a single TMJ orthotic appliance; however in many cases two appliances are needed, a day appliance and a night appliance. The amount of coverage is minimal and does not account for the many adjustments needed to properly help a TMD client.
Certain physical medicine modalities and/or injections may have benefits on the medical or dental insurance plans, however these are usually adjunct procedures to the orthotic appliance therapy and represent only a small portion of treatment cost. Treatment cost varies from State to State, and generally the fees in the Fort Worth/Dallas area are much less than states like California, so it is not uncommon for clients to travel long distances for treatment.
Insurance companies do not determine the standard of care for TMJ disorders. The American Dental Association has some good guidelines for care but is not a credentialling body. There are two credentialling bodies with concerns for TMD: the American Board of Craniofacial Pain and the American Board of Orofacial Pain. Unfortunately the ADA has blocked the recognition of specialty over the past years in the TMD field, and in my opinion that has hurt the patient ultimately and leads to the lack of insurance reimbursement and quality care. It is interesting that most insurance plans that cover TMJ surgery require non-surgical procedures first; the procedures that they don't pay for.
Dr. McCarty is board certified by the American Board of Craniofacial Pain and by the American Board of Craniofacial Dental Sleep Medicine. He will continue to treat patients at what he believes to be the highest level of care and does not compromise standard of care based on insurance codes and benefits.
Many of our clients sign up for interest free payments through Care Credit, so they can begin the work of reducing their pain at more affordable monthly payments. If you are interested in Care Credit you can go to www.carecredit.com and prequalify. Once on the CareCredit web site select provider locator, and then under the heading "Does My Doctor Accept Care Credit" type in our phone number 817-441-6875. You may then select Apply Now. Of course our office also accepts: checks, cash, or credit cards (Visa, MC, Discover, American Express, and most HSA cards).
Dr. McCarty is an out of network provider and is not a Medicare provider. He requires full payment for services at the time of service. Because he is an out of network provider, he cannot confirm whether or not the patient will have any insurance reimbursement. This office will as a courtesy send in dental claims for the patient. It no longer files for medical claims except for sleep apnea appliances. The office does not become involved in insurance disputes. The insurance provider will be asked to reimburse the patient directly.
Medicare patients will be required to sign an “opt out” agreement and will not be receive reimbursement from their Medicare. Since Medicare doesn't pay for appliance therapy for TMD anyway, the Medicare patient doesn't really lose out. Medicare recipients that have supplemental plans are usually required to use Medicare as their primary provider, and in those circumstances should expect no help from either the primary or supplemental insurance.