Medicare Coverage of TMJ (Transmandibular Joint)
What It Is
Care by a physician or oral surgeon of conditions involving the transmandibular joint (TMJ) of the jaw.
Medicare Part B covers TMJ care, including surgery, if it's performed by a medical doctor or by a Medicare-participating non-M.D. oral surgeon -- as long as it's the type of care that medical doctors also provide.
If it's the type of care that dentists provide but medical doctors don't, it's considered dental care, and Medicare doesn't cover it.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for TMJ care, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for covered TMJ care; patients are responsible for the remaining 20 percent.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be provided by a healthcare provider who participates in Medicare.
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