Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (CPT code 99244) to be provided by a 
maxillofacial surgeon. 
 
You asked the Plan to pre-approve the office visit. You say that you have been dealing with the pain and loss of 
hearing for almost year. You state that when the hearing loss and headaches started to get worse, you started to 
pursue treatment in the last six (6) months. The Plan denied your request. The Plan says you have been referred 
to an otolaryngologist, but you indicated that you wish to see an oral surgeon to be evaluated for 
temporomandibular joint dysfunction (TMJ). The Plan states the otolaryngologist can evaluate your pain 
adequately rather than oral surgeon, and TMJ is not covered by your Medicare Part B. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is limited and most of it is insurance carrier note references to the fact you 
had seen an otolaryngologist and there was noted hearing loss, clicking around the TMJs and increasing 
headaches. These symptoms can be associated with TMJ disorders; however, the hearing loss would likely be 
best assessed by an otolaryngologist.  Current records on their own do not definitively support a TMJ 
diagnosis. The documentation does support the contention that the service is focused on a medical condition 
rather than being related to services to treat the teeth and supporting structures. The TM joint is a functional 
joint in the body and does not directly involve the teeth. It is reasonable to have a consultation for a TMJ 
disorder when there is no other definitive diagnosis for the symptoms being experienced by you. TMJ 
symptoms can involve hearing disruption and headaches; however, hearing loss would likely need to be 
evaluated by an otolaryngologist, and this would most likely be the first step in localizing the symptoms being 
experienced by you. Due to the reported healing loss, an otolaryngologist would be the primary specialist to 
have a consultation with, followed by an oral surgeon if no clear cause can be found following that evaluation. 
Though TMJ issues can cause hearing issues, the basis for the hearing issues should be determined by the 
provider that specializes in hearing issues. If the otolaryngologist cannot determine the cause or treat the issue, 
then that specialist would refer to have a TMJ evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the office visit (CPT code 99244) to be provided by a maxillofacial surgeon.