The Department has received complaints related to the improper denial of coverage and preauthorization requests for medically necessary treatment of conditions affecting the temporomandibular joint. The purpose of this bulletin is to remind regulated entities that Insurance Code Chapter 1360 requires group health benefit plans that provide coverage for medically necessary diagnostic or surgical treatment of conditions affecting skeletal joints to provide comparable coverage for diagnostic or surgical treatment of conditions affecting the temporomandibular joint.
The coverage is required if the treatment is medically necessary as a result of an accident, a trauma, a congenital defect, a developmental defect or a pathology. Further, Section 1360.001 defines the term "temporomandibular joint" to include the jaw and the craniomandibular joint. For example, a health benefit plan might include limitations of coverage for reconstructive surgery for craniofacial abnormalities that otherwise comply with the requirements of Insurance Code Chapter 1367, Subchapter D, concerning child craniofacial abnormalities. The health benefit plan must still comply with the requirements of Chapter 1360. Coverage not required under Insurance Code Chapter 1367, Subchapter D, because the insured is 18 years old or older may still be required by Insurance Code Chapter 1360.
Insurance Code Chapter 1360 does not require a health benefit plan to provide coverage for dental services if dental services are not otherwise scheduled or provided as part of the coverage provided under the plan, but a health benefit plan may not exclude from coverage an individual who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the individual's physician or by the dentist providing the dental care.
See Section 1360.003 to determine whether an exception applies. If you have any questions or concerns regarding the application of state law in this area, please contact a member of the A&H Section at 512/322-3409 or the HMO Compliance Section at 512/322-4266.