Temporomandibular Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Botox injections every 12 weeks.Botox is a neurotoxin that inhibits acetylcholine release at the neuromuscular junction, effectively reducing muscle hyperactivity. Botox has been used to treat patients with refractory bruxism and oromandibular dystonia who have failed to respond to adequate attempts at first-line therapies. A study demonstrated that Botox can significantly improve pain, jaw function, and muscle activity in patients with sleep bruxism and temporomandibular (TMJ) symptoms, with a strong safety profile. A randomized, placebo-controlled trial showed that Botox led to statistically significant improvements in sleep bruxism frequency and facial pain, with no serious adverse events.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of temporomandibular joints (TMJ). The TMJ are the sole joints responsible for articulation and movement of the lower jaw. Pathologic conditions affecting the TMJ, and associated musculature and connective tissue of the lower jaw, are referred to as temporomandibular disorders (TMD). The symptoms of TMD include jaw pain, headaches, restricted jaw opening, joint dislocation, and frequently associated ear symptoms, such as ear pain and fullness. The diagnosis of TMD is typically made based on the patient’s medical history and physical examination. However, elucidating the exact nature of the derangement commonly requires further investigation with imaging.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox (onabotulinumtoxinA) injections. Temporomandibular disorders (TMD) represent a collection of pathologies that involve the temporomandibular joints and/or the muscles related to mastication and associated connective tissues. Researchers explain that the diagnosis of TMD is based on presenting symptoms and correlative findings on physical examination. Symptoms may include headache, localized pain around the jaw and ear, and trismus, with a physical examination demonstrating localized tenderness with palpation of the joint space and/or associated muscles of mastication, and/or dysfunction of the joints, such as popping and clicking, and/or limited jaw opening.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Botox injections. A concise review of the literature regarding current management options/guidelines for temporomandibular disorder (TMD) recommends physical therapy and acupuncture/dry needling. A systematic review and meta-analysis found that Botox was only slightly more effective than placebo at reducing pain at one month, with no differences existing at three and six months, and that facial manipulation, or physical therapy, was more effective than Botox at pain reduction at three months.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for temporomandibular disorder was denied, the published record says the denial is worth fighting.