Temporomandibular Joint Dysfunction denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 47-year-old female with chronic pain and temporomandibular joint dysfunction. She has requested authorization and coverage for Botox indicating it has reduced her need for Ultram by 50%. The patient continues to have moderate pain. The Health Plan has denied coverage for Botox therapy on the basis it is considered experimental for treatment of the patient’s medical condition.Review of the medical literature reveals little evidence to support the use of Botox for myofascial pain. The relevant literature mostly involves open label trials and case report series and is quite limited. Furthermore, the submitted clinical information does not provide sufficient detail regarding the patient’s attempts at standard therapy. It appears standard therapy, which may include surgery, is more likely to be effective for this patient than Botox therapy.

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for computed tomography (CT). Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. Temporomandibular joint dysfunction is an umbrella term used to describe pain and dysfunction of the muscles and skeletal structures involved in mastication. It is a symptom complex, as opposed to a specific disease or illness, and as much as 20-30% of the entire adult population is affected at some point in their lives. Etiologies range from a simple dental abnormality, such as an uneven dental filling, to significant malformations of the temporomandibular joint. As such, there is considerable variation in the diagnostic evaluation.

Where the denial was upheld

Physician 1: The patient is a 35-year-old female with temporomandibular joint dysfunction and associated head and neck pain. Treatment with physical therapy produced significant improvement in symptoms. The submitted evidence does not demonstrate that she has been treated with a combination of dental occlusal splinting, analgesics and physical therapy. Orthotic splinting and occlusal equilibration has not been performed and the patient’s symptoms have recurred.A request has been made for authorization and coverage for an electromyography (EMG).

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for Botox injections. Temporomandibular joint dysfunction is a term used to describe pain and dysfunction of the muscles of mastication and the temporomandibular joints. The authors of a study explained that temporomandibular disorders have a range of causes and often co-occur with overlapping medical conditions such as headaches, fibromyalgia, and back pain. While there are many treatments available, there is a general lack of evidence for any treatments for temporomandibular disorders, and there is no widely accepted treatment protocol.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving temporomandibular joint dysfunction, then check the rights and deadlines that apply to your plan.