MMC Benefits Handbook
Temporomandibular Joint (TMJ) Coverage
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
The Plan covers services for diagnostic and surgical treatment of conditions affecting the temporomandibular joint when provided by and under the direction of a physician. Coverage includes the diagnostic or surgical treatment required as a result of an accident, trauma, congenital defect, developmental defect or pathology.
  • Diagnostic coverage includes examination, radiographs and applicable imaging studies, and consultation.
  • Non-surgical treatment includes clinical examinations, oral appliances (orthotic splints), arthrocentesis and trigger-point injections. Surgical treatment* includes arthrocentesis, arthroscopy, arthroplasty, arthrotomy, open or closed reduction of dislocations and TMJ implants.
*Surgical treatment is provided if the following criteria are met:
    • There is clearly demonstrated radiographic evidence of significant joint abnormality.
    • Non-surgical treatment has failed to adequately resolve the symptoms.
    • Pain or dysfunction is moderate or severe.