Benefits for Temporomandibular Joint (TMJ) Dysfunction Syndrome. To the extent this Contract provides benefits for office visits, diagnostic dental imaging services, etc. for medical conditions, the following services are also covered under the medical (not dental) coverage of this Contract, applying appropriate Deductibles, Coinsurances, Copayments, shared payments: (1) Only one of the following are eligible for benefits and will be subject to the home or office visit payment provisions: (a) A clinical evaluation, to include examination, history, ordering of necessary diagnostic procedures (such as radiographs, study models if necessary, muscle testing), evaluation of results and consultation with the patient. (b) A total diagnostic evaluation including, but not limited to, history, examination, radiographs, study models and a patient consultation. (2) Diagnostic services, including but not limited to: (a) Panoramic radiographs (b) Cephalometric radiographs with tracing (c) Temporomandibular joint tomography (d) Temporomandibular joint arthrography (e) Skull series; computerized tomography of temporomandibular joint (f) Manual muscle testing procedures And one of the following: (g) Electromyography of cranial supplied nerves (h) Electronic computerized neuromuscular testing (i) Oscilloscopic neuromuscular testing The maximum benefit payment (after application of any payment provisions) will be the Company's allowable amount for conventional electromyography, or neuromuscular-type test. (3) Non-surgical initial treatment procedures (reversible Phase I) limited to: (a) Orthopedic repositioning appliances (maxillary or mandibular). (b) Orthopedic (orthotic) splints (such as nite-guards, biteblocks, bite openers, bite plates, muscle de-programmer). (c) Physical therapy procedures (limited to transcutaneous electrical nerve stimulators, Galvanic stimulation, ultrasound, diathermy). (d) Trigger point injections These services are subject to the provisions of the Insured's medical benefits program. (a) Equilibration of occlusion (b) Massage, either manual or by machine
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Samples: Comprehensive Major Medical Group Contract, Comprehensive Major Medical Group Contract, Comprehensive Major Medical Group Contract
Benefits for Temporomandibular Joint (TMJ) Dysfunction Syndrome. To the extent this Contract provides benefits for office visits, diagnostic dental imaging services, etc. for medical conditions, the following services are also covered under the medical (not dental) coverage of this Contract, applying appropriate Deductibles, Coinsurances, Copayments, shared payments:
(1) Only one of the following are eligible for benefits and will be subject to the home Home or office visit Office Visit payment provisions:
(a) A clinical evaluation, to include examination, history, ordering of necessary diagnostic procedures (such as radiographs, study models if necessary, muscle testing), evaluation of results and consultation with the patient.
(b) A total diagnostic evaluation including, but not limited to, history, examination, radiographs, study models and a patient consultation.
(2) Diagnostic services, including but not limited to:
(a) Panoramic radiographs
(b) Cephalometric radiographs with tracing
(c) Temporomandibular joint tomography
(d) Temporomandibular joint arthrography
(e) Skull series; computerized tomography of temporomandibular joint
(f) Manual muscle testing procedures And one of the following:
(g) Electromyography of cranial supplied nerves
(h) Electronic computerized neuromuscular testing
(i) Oscilloscopic neuromuscular testing The maximum benefit payment (after application of any payment provisions) will be the Company's allowable amount for conventional electromyography, or neuromuscular-type test.
(3) Non-surgical initial treatment procedures (reversible Phase I) limited to:
(a) Orthopedic repositioning appliances (maxillary or mandibular).
(b) Orthopedic (orthotic) splints (such as nite-guards, biteblocks, bite openers, bite plates, muscle de-programmer).
(c) Physical therapy procedures (limited to transcutaneous electrical nerve stimulators, Galvanic stimulation, ultrasound, diathermy).
(d) Trigger point injections These services are subject to the provisions of the Insured's medical benefits program.
(a) Equilibration of occlusion (b) Massage, either manual or by machine
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