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When you open your mouth or chew, TMJ disorders can produce a clicking sound or grating sensation.
TMJ can also cause jaw pain or tenderness. And although it does not seem like a big problem, it can be.
If this is an issue you are dealing with and would like treatment for, you likely have the question, “Does Medicare cover TMJ problems?”
In this article, we answer the question in clear, plain English along with some other helpful info about treating this problem.
Does Medicare Cover TMJ Problems?
The short answer is maybe. Medicare may cover the cost of treatments for TMJ problems. But not 100% of the time.
As is often the case with Medicare, certain conditions must be met for Medicare to pay for your treatments for TMJ. Below we look at what these are so you know what to expect.
Original Medicare Coverage of TMJ Problems
Original Medicare (Medicare Part A and Part B) may provide coverage for treatments for TMJ. However, coverage is offered for treatment if it is considered medically necessary.
Your healthcare provider must first order any treatment for Original Medicare to provide coverage. Then, and only then, they may provide coverage for TMJ surgery if it is medically necessary.
When Does Part A Provide Coverage?
Coverage for TMJ surgery is provided by Medicare Part A if your TMJ treatment (such as surgery) takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
When Does Part B Provide Coverage?
However, most of the time, TMJ treatments take place in an outpatient setting. In this case, coverage for your TMJ treatment is provided by Medicare Part B if it takes place in an outpatient setting. Once approved, Medicare Part B covers 80 percent of the costs of TMJ treatment. You will pay for the remaining 20 percent.
Medicare Advantage Coverage of TMJ Problems
Medicare Advantage plans (Medicare Part C) also provide coverage for TMJ surgery. These plans have a requirement that they must cover everything Original Medicare covers.
Part C plans also offer additional benefits (often this includes dental and hearing-related services) that Original Medicare does not cover. Exactly what a plan covers and how much the out-of-pocket costs are will vary depending on your plan.
When Does Part D Provide Coverage?
Medicare Part D plans provide coverage for medications that you may need after TMJ surgery. Additionally, Part D also provides coverage for prescription medications for TMJ.
Medicare Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.
Does Medicare Cover TMJ Physical Therapy?
Medicare may provide coverage for physical therapy for TMJ. There is no written guideline yet about whether Original Medicare provides coverage for physical therapy for TMJ.
But according to the general medicare guidelines, you should receive coverage for physical therapy if it is medically necessary. Your healthcare provider must first order the operation for Original Medicare to provide coverage.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series, including: Does Medicare Cover Mohs Surgery?