TMJ syndrome, often referred to simply as TMJ, is a disorder that affects the temporomandibular joint, and people who suffer from this medical condition may experience pain, pressure, tension and limited range of motion when opening and closing the mouth. This is because the temporomandibular joint is located at the point where the bottom jaw, or mandible, connects to the skull right below the ears. TMJ is often caused by various types of arthritis, including osteoarthritis and rheumatoid arthritis, but it can also be caused by trauma to the joint. As a result, TMJ often affects older individuals who are eligible to receive Medicare coverage.

How is TMJ Treated?

Treatment options for TMJ vary depending on the cause and the severity of symptoms. At-home treatments may include over-the-counter pain relievers and anti-inflammatory medications, alternating heat and cold compresses and meditation to induce relaxation. Those suffering from mild TMJ may find it beneficial to pay close attention to the position of the jaw and teeth when resting, and those affected by TMJ mare also encouraged to avoid hard foods that may make symptoms worse. If at-home treatment is not an option or if symptoms do not alleviate, prescription medications or surgery may be required to address inflammation or to correct underlying structural problems and entrapment of nerves and joint tissue.

Does Medicare Cover TMJ Treatment?

In general, Medicare insurance will not cover the cost of at-home treatments because these usually consist of the aforementioned over-the-counter medications and muscle relaxation techniques. If a prescription medication is ordered by a doctor, Medicare may provide coverage under Part D according to the plan’s formulary. In instances where durable medical equipment is utilized, Medicare may provide coverage under Part B, but ice packs and similar products might not fall under this part of Medicare.

If surgery is required, Medicare may cover the procedure under Part A if the surgery is deemed medically necessary and you are formally admitted into the hospital. Part B may help cover the costs of your procedure if it takes place in an outpatient setting. Surgical procedures are also considered a last resort, so if you’re facing TMJ, your Medicare benefits may not apply until you and your doctor have attempted other less-invasive treatments first.

Part of the concern in obtaining surgical treatment among Medicare members who suffer from TMJ is that treatment for this disorder exists in a middle ground between dental and medical specialties. Original Medicare does not offer routine dental benefits, but some Medicare Advantage plans may provide coverage. As a result, it’s very important to work closely with your primary care physician and any non-dental specialists when seeking Medicare coverage for TMJ.

These individuals will be responsible for ensuring that your request for coverage is worded and framed in such a way as to distinguish your need for surgery as one that is not directly related to a dental problem. In doing so, they can make sure that Medicare understands that you are facing a joint problem. This can improve your odds of receiving approval when Medicare understands that you are in need of medical surgery and not dental surgery.

Does Medicare Cover TMJ Treatment Recovery?

As with the actual treatment, Medicare insurance may or may not cover recovery for TMJ surgery; however, medications prescribed for recovery will likely be covered under Medicare Part D regardless of whether surgery is covered. TMJ treatment recovery is usually undertaken at home, but in cases where someone has been hospitalized and needs to be temporarily placed into a skilled nursing facility, Medicare Part A may help cover your costs.

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