Insurance Coverage for Treatment of Temporomandibular Joint Dysfunction or Surgery for Deformities of Maxilla or Mandible

  1. Law
  2. Georgia Code
  3. Insurance
  4. Individual Accident and Sickness Insurance
  5. Insurance Coverage for Treatment of Temporomandibular Joint Dysfunction or Surgery for Deformities of Maxilla or Mandible

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  1. As used in this Code section, the term:
    1. "Functional deformity" means a deformity of the bone or joint structure of the maxilla or mandible such that the normal character and essential function of such bone structure is impeded.
    2. "Policy" means any major medical benefit plan, contract, or policy except a credit insurance policy, disability income policy, specified disease policy, hospital indemnity policy, limited accident policy, or other similarly limited accident and sickness policy.
    3. "Temporomandibular joint" means the connection of the mandible and the temporal bone through the articular disc surrounded by the joint capsule and associated ligaments and tendons.
    4. "Temporomandibular joint dysfunction" means congenital or developed anomalies of the temporomandibular joint.
  2. No policy may be issued or issued for delivery in this state which:
    1. Excludes medically necessary surgical or nonsurgical treatment for the correction of temporomandibular joint dysfunction by physicians or dentists professionally qualified by training and experience; or
    2. Excludes medically necessary surgery for the correction of functional deformities of the maxilla and mandible.
  3. The provisions of this Code section shall not cover cosmetic or elective orthodontic or periodontic care or general dental care.
    1. The coverage under paragraph (1) of subsection (b) of this Code section may contain such types of exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions which apply to other benefits under the accident and sickness insurance benefit plan, policy, or contract.
    2. Basic coverage for the nonsurgical treatment of temporomandibular joint dysfunction under paragraph (1) of subsection (b) of this Code section may be limited to history and examination; radiographs, which must be diagnostic for temporomandibular joint dysfunction; splint therapy with necessary adjustments, provided that removable appliances designed for orthodontic purposes would not be reimbursable under a major medical plan; and diagnostic or therapeutic masticatory muscle and temporomandibular joint injections.
  5. Except as provided in paragraph (1) of subsection (c) of Code Section 33-30-23, for policies limited only to dental coverage, nothing contained in this Code section shall be deemed to prohibit the payment of different levels of benefits or from having differences in coinsurance percentages applicable to benefit levels for services provided by preferred and nonpreferred providers as otherwise authorized under the provisions of Article 2 of Chapter 30 of this title, relating to preferred provider arrangements.

(Code 1981, §33-29-20, enacted by Ga. L. 1994, p. 474, § 1; Ga. L. 2019, p. 386, § 96/SB 133.)

The 2019 amendment, effective July 1, 2019, deleted "the Georgia Basic Health Plan," following "policy except" near the middle of paragraph (a)(2).

Cross references.

- Group or blanket insurance coverage for treatment of temporomandibular joint dysfunction or surgery for deformities of maxilla or mandible, § 33-30-14.

Editor's notes.

- Ga. L. 1994, p. 474, § 3, not codified by the General Assembly, provides that the Act shall be applicable to individual, group, or blanket major medical policies issued or issued for delivery on or after July 1, 1994.


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