Amendment — Oral Surgery/TMJ Benefits (Health Plan for State of Louisiana Employees and Retirees)
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Amendment to the Health Plan for State of Louisiana Employees and Retirees governing coverage and prior authorization for diagnosis, therapeutic, or surgical procedures related to TMJ disorders and associated musculature/neurological conditions.
Language covering diagnosis, therapeutic, or surgical procedures related to Temporomandibular Joint (TMJ) disorders and associated musculature and neurological conditions was deleted from the Oral Surgery and Dental Services Article.
Coverage Criteria
This amendment removes prior policy language that specifically addressed coverage for diagnosis, therapeutic, or surgical procedures related to Temporomandibular Joint (TMJ) disorders and associated musculature and neurological conditions from the Oral Surgery and Dental Services Article. The deleted text previously appeared in Section 5 of the Dental Services provisions of the Plan documents listed and referenced that such services may require prior authorization as shown on the member’s Schedule of Benefits. All other provisions of the Plan not changed by this amendment remain in full force and effect, and the amendment is effective 01/01/2025 for the listed benefit plans.
Provider Actions and Authorization
Prior authorization requirement for TMJ services
Prior authorization may be required for TMJ-related diagnostic, therapeutic, or surgical services per the member's Schedule of Benefits.
Confirm authorization and coverage via Schedule of Benefits
Follow the Plan's Schedule of Benefits for any prior authorization, coverage, or claim submission requirements that apply to TMJ-related services.
Follow Schedule of Benefits
Providers must follow the member's Schedule of Benefits to determine whether prior authorization is required for diagnosis, therapeutic, or surgical procedures related to TMJ disorders.
Prior authorization may be required — denial risk
Services for diagnosis, therapeutic, or surgical procedures related to TMJ disorders may require prior authorization as shown on the member's Schedule of Benefits; failure to obtain required authorization may affect coverage.
Background
Temporomandibular joint (TMJ) disorders encompass conditions affecting the TMJ itself, the associated masticatory musculature, and related neurological structures. Clinical evaluation may include diagnostic assessments to characterize joint and muscle involvement, and management options range from conservative therapeutic approaches to procedural or surgical interventions when indicated. Whether these diagnostic, therapeutic, or surgical services are covered or require prior authorization is governed by the member’s Schedule of Benefits and the Plan’s Dental/Oral Surgery provisions.
Definitions
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