Insurance Companies Win And Patients Lose With Denials Of TMD Care

“Reports from the TMJ Association and national media show a consistent pattern; insurers deny splints under medical benefits because they belong to dental but deny them under dental benefits because they’re “medical”.

While you as a patient or a member of our billing staff argues with a call-center rep over reimbursing an oral splint, big insurance companies are doing just fine. UnitedHealth Group reported more than $22 billion in profit in 2023, and its CEO alone took home roughly $26.3 million last year [1,2]. Elevance Health (Anthem) cleared its own multibillion-dollar margins with a CEO payout of about $20.5 million; Cigna Group’s CEO collected around $23.25 million; and Humana’s CEO sat comfortably at approximately $15.6 million in total 2024 compensation [2,3]. But the story isn’t just executive pay; UnitedHealth is under federal investigation for allegedly misusing Medicare Advantage billing practices [4], Cigna is facing scrutiny for algorithm-driven claim denials that reportedly reject large volumes of claims without meaningful review [5], and several insurers have been named in False Claims Act actions tied to risk-coding schemes in Medicare Advantage plans [6]. And yet these same companies routinely deny conservative TMJ care like splints, injections, and physical therapy, often with the click of a template denial button.

Temporomandibular disorder (TMD) sits at a unique intersection; it is a musculoskeletal pain disorder that straddles medicine, dentistry, neurology, psychology, and physical therapy, and the National Academies has already warned that coverage is fragmented, inconsistent, and often excludes the very conservative treatments that work best [7]. Reports from the TMJ Association and national media show a consistent pattern; insurers deny splints under medical benefits because they “belong” to dental but deny them under dental benefits because they’re “medical” [8,9]. And when splints are billed under TMJ-specific codes, denial rates spike even higher. Clinical advisories routinely note that payers flag simple language like “TMJ,” “appliance,” or “medically necessary” as triggers for down-coding or outright refusal. Prior authorization data from the American Medical Association shows the same trend across chronic pain: automated systems now delay or block necessary treatment for millions of patients, often without physician review [10].

As a patient, your insurance rep will often tell you that you have coverage for medical necessity but will tell our staff the opposite. Hence, I cannot stress enough that anytime you as a patient call your insurance company, please take down the representative’s name and reference number of that conversation – if you are lucky enough to even talk to a real person at the insurance company, as many insurance companies now use Artificial Intelligence (AI) to communicate with patients.

I would be remiss if I did not point out that there are bad actors who misuse insurance coverage for increased reimbursements. A specialty dental practice in Wisconsin settled with the Department of Justice (DOJ) under the False Claims Act for miscoding splints used for TMD [11]. Cases like that give insurers ammunition; but they do not justify the blanket denials that now define the TMD landscape.

In conclusion, TMD is a legitimate musculoskeletal condition, often chronic, often disabling, and best managed with safe, conservative, interdisciplinary care. Until payers treat the jaw the same way they treat knees or hips, patients will keep paying twice; once in premiums, and again when their EOB shamelessly declares that their jaw falls outside the definition of “health.” I can guarantee that insurance company’s CEO drives cars much nicer than my 2022 Toyota Rav4 Hybrid.

References

1. UnitedHealth Group. UnitedHealth Group Reports 2023 Results. January 12, 2024. https://www.unitedhealthgroup.com/content/dam/UHG/PDF/investors/2023/UNH-Q4-2023-Release.pdf

2. Wilson R. Highest-paid payer CEOs in 2024. Becker's Payer Issues. April 23, 2025. https://www.beckerspayer.com/payer/highest-paid-payer-ceos-in-2024/

3. Fierce Healthcare. A look at what major payer CEOs earned in 2024. 2025. https://www.fiercehealthcare.com/special-reports/unitedhealth-ceo-andrew-witty-was-2024s-highest-paid-payer-ceo-heres-look-what

4. UnitedHealth Group. Investigations Related to Medicare Advantage Billing Practices; publicly reported DOJ inquiries. 2025. https://www.wha.org/news/legislative-edition/2025/02-28-2025/2

5. ProPublica. How Cigna Saves Millions by Having Its Doctors Reject Claims Without Meaningful Review. 2023. https://www.propublica.org/article/cigna-health-insurance-denials-pxdx-congress-investigation

6. US Department of Justice. Medicare Advantage Risk-Coding False Claims Act Filings; summaries of actions against multiple national insurers. https://www.justice.gov/usao-sdny/pr/united-states-reaches-37-million-settlement-fraud-lawsuit-against-cigna-submitting https://www.justice.gov/archives/opa/pr/medicare-advantage-provider-independent-health-pay-98m-settle-false-claims-act-suit

7. National Academies of Sciences, Engineering, and Medicine. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC; 2020. https://www.nationalacademies.org/projects/HMD-HSP-18-21

8. TMJ Association. Insurance Barriers to TMD Care. https://tmj.org/a-bottomless-pit-how-out-of-pocket-costs-drive-tmj-patients-into-debt/

9. CBS News. TMJ Patients Face High Out-of-Pocket Costs for Conservative Care. 2024. https://www.cbsnews.com/news/how-tmj-costs-drive-patients-into-debt

10. American Medical Association. 2024 Prior Authorization Physician Survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

11. US Attorney’s Office, Eastern District of Wisconsin. TMJ & Orofacial Pain Treatment Centers of Wisconsin Agree to Pay $1 Million to Resolve False Claims Act Allegations. https://www.justice.gov/usao-edwi/pr/tmj-orofacial-pain-treatment-centers-wisconsin-agree-pay-1-million-resolve-false-claims