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Appendix C - Temporomandibular Joint Disorder Treatment <br />Temporomandibular Joint Disorder (TMJ) means a disorder that has one or more of the following <br />characteristics: pain in the musculature associated with the temporomandibular joint; internal <br />derangements of the temporomandibular joint; arthritic problems with the temporomandibular joint; or an <br />abnormal range of motion or limitation of motion of the temporomandibular joint. <br />1. Benefits. Benefits for treatment of TMJ are limited to a yearly benefit maximum of $1,000 per <br />Enrollee and a lifetime benefit maximum of $5,000 per Enrollee. <br />2. Limitations and Exclusions. <br />a. TMJ treatment is covered only if the Participating Provider prepares the treatment plan prior to <br />starting treatment and provides the treatment. <br />b. The repair or replacement of lost, stolen, or broken TMJ appliances is not covered. <br />c. To be covered, the Covered Services must be: <br />1) Reasonable and appropriate for the treatment of TMJ; <br />2) Effective for the control or elimination of pain, infection, disease, difficulty in speaking, or <br />difficulty in chewing or swallowing food, which is caused by TMJ; <br />3) Recognized as effective, in accordance with the professional standard of care; <br />4) Not deemed Experimental or Investigational; and <br />5) Not primarily intended to improve, alter, or enhance appearance. <br />001 L-WA81 1 (5/20) 30 <br />