The plan covers diagnostic and surgical and non-surgical treatment of conditions affecting the temporomandibular joint (TMJ) when provided by or under the direction of a physician.
Coverage includes necessary treatment required as a result of accident, trauma, a congenital anomaly, developmental defect, or pathology. Diagnostic treatment includes examination, radiographs and applicable imaging studies and consultation. Non-surgical treatment includes clinical examinations, oral appliances (orthotic splints), arthrocentesis and trigger-point injections. Coverage is not provided for any orthodontic and prosthetics devices, including but not limited to braces or mouth guards.
Benefits are provided for surgical treatment if:
- there is clearly demonstrated radiographic evidence of significant joint abnormality;
- non-surgical treatment has failed to adequately resolve the symptoms;
- and pain or dysfunction is moderate or severe.
Benefits for surgical services include arthrocentesis, arthroscopy, arthroplasty, arthrotomy, open or closed reduction of dislocations.
- Coverage for non-surgical treatment is limited to $2,000 per covered person per lifetime.
- Coverage is limited to one surgical session per covered person per lifetime.
If the student is seen at an in-network provider, Student Health Services will pay 80% of the reasonable and customary covered expenses and the student will be responsible for 20% of such expenses.