Why TMJ Isn’t Always Covered by Insurance—and How Physical Therapists Navigate It
If you’ve been struggling with jaw pain, headaches, clicking, or facial tension, you may be surprised to learn that temporomandibular joint dysfunction (TMJD or TMJ) isn’t always covered by your health insurance—even when it’s causing real, daily problems. But we can fix that!
Why Insurance Often Denies TMJ Coverage
TMJ disorders fall into a bit of a gray area. Some insurers consider it a dental issue (not medical), even when it clearly affects your ability to eat, talk, sleep, or function. Others limit coverage, capping visits or excluding TMJ treatment outright unless very specific criteria are met.
This can be frustrating for patients—and for the providers trying to help them.
How Physical Therapists Work Within the System
Here’s the truth: we don’t commit insurance fraud. Ever. But we do look at the bigger picture.
The jaw doesn’t exist in isolation. It interacts constantly with the neck, face, head, and even the upper back and shoulders. That means:
A tight neck or poor posture can overload the jaw
Tension in the face or head can cause jaw clenching
TMJ dysfunction can trigger neck pain, headaches, or even shoulder issues
So when someone comes in with jaw symptoms, we often find treatable impairments in adjacent areas. These can be properly diagnosed and coded—legally and ethically—under musculoskeletal diagnoses like:
Cervicalgia (neck pain)
Myalgia (muscle pain)
Postural dysfunction
Headaches (tension-type)
Cervicogenic dizziness
Stress-related muscle tension
These diagnoses aren’t “workarounds”—they’re clinically appropriate. Treating these areas supports jaw function and is medically necessary in many cases.
Sometimes It Is a TMJ Code—But It Has to Be the Right One
Another layer of complexity? Even when TMJ is covered, some diagnosis codes are accepted while others get denied—and it’s not always consistent.
We might use a code like:
M26.621 (arthralgia of temporomandibular joint)
M79.11 (myalgia of mastication muscle)
Only to have one approved and the other denied. Unfortunately, we often don’t know which codes an insurer will accept until a claim is processed.
The good news: we can often resubmit using another accurate, medically appropriate code that reflects your condition and gets your care covered.
Most people with TMJ issues don’t just have one thing going on—they might have arthralgia, myalgia, disc displacement, or arthritis, all in the same joint. That means multiple accurate diagnoses are often available, and choosing the right one can make all the difference.
Stress, Sleep, and the Bigger Picture
TMJ is rarely just a “jaw” issue. Stress, anxiety, and sleep dysfunction often play a role.
Physical therapy can’t fix every underlying factor, but we can:
Calm the nervous system
Improve breathing patterns
Release chronic muscle tension
These changes often improve jaw symptoms—even when TMJ isn’t directly covered.
Bottom Line
If your insurance doesn’t cover TMJ directly, that doesn’t mean you’re out of options.
An experienced physical therapist will:
Assess your whole system
Identify medically necessary areas to treat
Work within legal and ethical bounds
Help you get the relief you need
Ready to Start Feeling Better?
I treat patients in the Glen Allen and greater Richmond, VA area at H2 Health.
If you’re dealing with jaw pain, headaches, neck tension, or anything related to TMJ dysfunction, we can figure out the best path forward—even if insurance coverage is complicated.
👉 Schedule an appointment at H2 Health Richmond in Glen Allen, Virginia
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Note: The views expressed in this blog are my own and do not necessarily reflect those of my employer.