TMJ and Texas Insurance Law and Code
Serving Houston, Baytown, La Porte, Pasadena, and Port Arthur
“Medical necessity refers to treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.”
Texas
Under Texas law, if benefits are provided for diagnostic and/or surgical treatment of skeletal joints, the insurance policies must provide the same for treatment of TMD and CMD joints.
TEMPOROMANDIBULAR JOINT (TMJ) - Article 21.53A, Texas Insurance Code |
Benefits for TMJ must be provided when benefits for other medically necessary diagnostic or surgical treatment of skeletal joints are provided. |
Applicable to a group health benefit plan that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans. |
HOUSE BILL 2063 (HB 2063) relating to Diagnosis and Treatment of Conditions Affecting the Temporomandibular Joint (TMJ) and Dental Services SECTION 1 amends Article 21.53A, Texas Insurance Code
Effective Date of Statute: 9/1/97
HB 2063 – Continued
Required Benefit for Diagnosis and Treatment Affecting TMJ - Each group health benefit plan that provides benefits for the medically necessary diagnostic or surgical treatment of skeletal joints must provide comparable coverage for the medically necessary diagnostic or surgical treatment of conditions affecting the TMJ. TMJ includes the jaw and the craniomandibular joint - Article 21.53A, Sec. 3(a).
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Articles 20A and 21.58A, (c) summary plan descriptions and submit in accordance with 28 TAC §§7.1901-7.1910; and (d) any other internal documents.
Following considerable discussion at the 1998 Interim Meeting, the House of Delegates established the following AMA definition of “medical necessity” (Policy H-320.953[3], AMA Policy Compendium):
Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient, physician, or other health care provider.
The definition was adopted from a report of the Council on Medical Service (CMS Report 13, I-98) that was prepared primarily to address the growing problem of some health plans attempting to insert egregious definitions of medical necessity into managed care contracts. A number of these definitions included “lowest cost criteria” that often would define medical necessity in the context of the shortest, least expensive or least intense level of treatment, care or service provided. The House also adopted several other policy recommendations to augment the AMA’s comprehensive policy base on medical review, such as advocating that determinations of medical necessity should be based only on information that is available at the time that health care services and products are provided (Policy H-320.953[7]).
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