PRINTER'S NO. 1256
No. 1110 Session of 1997
INTRODUCED BY NAILOR, MICOZZIE, D. W. SNYDER, MASLAND, GEORGE,
OLASZ, PETTIT, MANDERINO, SEMMEL, LYNCH, ARGALL, COY, KENNEY,
BELARDI, C. WILLIAMS, FAIRCHILD, SCRIMENTI, CURRY, PRESTON,
JOSEPHS, HENNESSEY, TRAVAGLIO, BENNINGHOFF, E. Z. TAYLOR,
ROHRER, ROBERTS, YOUNGBLOOD, BOSCOLA, TRELLO, RAMOS,
STEELMAN, MARSICO, ROSS AND EGOLF, APRIL 2, 1997
REFERRED TO COMMITTEE ON INSURANCE, APRIL 2, 1997
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," providing for insurance coverage
12 for treatment of temporomandibular joint dysfunction and
13 surgery, if medically necessary, for deformities of the
14 maxilla or mandible.
15 The General Assembly of the Commonwealth of Pennsylvania
16 hereby enacts as follows:
17 Section 1. The act of May 17, 1921 (P.L.682, No.284), known
18 as The Insurance Company Law of 1921, is amended by adding a
19 section to read:
20 Section 633. Coverage for Treatment of Temporomandibular
21 Joint Dysfunction and Surgery, if Medically Necessary, for
22 Deformities of the Maxilla or Mandible.--(a) This section shall
1 apply to any individual or group health, sickness or accident
2 policy or subscriber contract or certificate issued by any
3 entity subject to 40 Pa.C.S. Ch. 61 (relating to hospital plan
4 corporations) or 63 (relating to professional health service
5 plan corporation), this act, the act of December 29, 1972
6 (P.L.1701, No.364), known as the "Health Maintenance
7 Organization Act," or the act of December 14, 1992 (P.L.835,
8 No.134), known as the "Fraternal Benefit Societies Code," which
9 provides hospital or medical/surgical coverage.
10 (b) If an insurance policy, contract or certificate provides
11 coverage for benefits to a resident of this Commonwealth, it
12 shall be deemed to be delivered in this Commonwealth, regardless
13 of whether the insurer issuing or delivering the policy is
14 located within or outside of this Commonwealth.
15 (c) No policy may be issued for delivery in this
16 Commonwealth which:
17 (1) excludes medically necessary nonsurgical or surgical
18 treatment for temporomandibular joint dysfunction by
19 professionals qualified by education, training and experience;
20 or
21 (2) excludes medically necessary surgery for the treatment
22 of functional deformities of the maxilla and mandible.
23 (d) The provisions of this section shall not cover cosmetic
24 or elective orthodontic or periodontal care or general dental
25 care.
26 (e) Nothing in subsection (c)(1) and (2) shall be construed
27 to prevent the application of the deductible, co-insurance or
28 pre-existing condition limitation contained in the policy,
29 contract or certificate.
30 (f) A definition of pre-existing condition does not prohibit
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1 an insurer from using an application form designed to elicit the
2 complete health history of the applicant, and on the basis of
3 the answers on that application, from underwriting in accordance
4 with that insurer's established underwriting standards. Unless
5 otherwise provided in the policy, contract or certificate, a
6 pre-existing condition need not be covered until the waiting
7 period is satisfied, as indicated in the policy, contract or
8 certificate. No policy, contract or certificate may exclude or
9 use waivers or riders of any kind to exclude, limit or reduce
10 coverage or benefits for specifically named or described pre-
11 existing diseases or physical conditions beyond the waiting
12 period described in the policy, contract or certificate.
13 (g) Policies, contracts or certificates shall contain a
14 twenty-five thousand dollar ($25,000) lifetime maximum for
15 nonsurgical procedures. The lifetime maximum of the policy shall
16 be applied to surgical procedures. The twenty-five thousand
17 dollar ($25,000) lifetime maximum for nonsurgical procedures
18 does not prevent the company from exercising the option to grant
19 additional benefits for nonsurgical procedures if it is more
20 cost effective than providing benefits for surgery.
21 (h) Ninety (90) days after a nonsurgical procedure, the
22 provider of treatment is required to provide documentation and a
23 narrative, signed by the patient, to the insurer showing the
24 progress of the insured. If the documentation and narrative do
25 not show satisfactory progress, benefits are terminated until a
26 second opinion is received. If the second opinion differs from
27 the treating provider, a revised treatment plan is required. If
28 the second opinion, due to a valid reason, does not differ from
29 the current treatment, the current treatment shall be continued
30 for an additional ninety (90) days at which time the treatment
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1 plan will be re-evaluated.
2 (i) Insurers shall require preauthorization for coverage,
3 and providers of treatment shall use a uniform preauthorization
4 request form and follow certain standards which include
5 evidence-based standards and patient-centered standards in
6 determining whether treatment is medically necessary. The
7 following apply:
8 (1) An insurer shall require a preauthorization for
9 nonsurgical treatment, and the provider of treatment shall
10 submit a properly completed Temporomandibular Joint Dysfunction
11 Nonsurgical Treatment Preauthorization Request Form.
12 (2) An insurer shall require a preauthorization for surgical
13 treatment for coverage, and the provider of treatment shall
14 submit a properly completed Temporomandibular Joint Dysfunction
15 Surgical Treatment Preauthorization Request Form.
16 (3) In cases of emergency, the preauthorization form shall
17 be submitted no later than forty-eight (48) hours after the
18 emergency treatment. Providers are permitted only two (2)
19 emergencies with the same patient within one (1) week without
20 preauthorization prior to treatment providing the
21 preauthorization is submitted no later than forty-eight (48)
22 hours after the emergency treatment.
23 (4) The following are standards and requirements for
24 evaluation of claims for temporomandibular dysfunction for
25 medical necessity:
26 (i) To evaluate appropriately a claim for treatment of this
27 disorder, the existence of a skeletal and/or muscular
28 dysfunction shall be documented.
29 (ii) Any maldevelopment that is not treatable with
30 conventional, reversible, nonsurgical treatment, yielding a
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1 stable and functional post-treatment occlusion without worsening
2 the patient's original condition, shall be a covered surgical
3 procedure.
4 (iii) Indications for nonsurgical and surgical treatments
5 shall include evidence of the following:
6 (A) Physical evidence of musculoskeletal, dento-osseous or
7 soft tissue deformity.
8 (B) Imaging evidence of musculoskeletal, dento-osseous or
9 soft tissue deformity.
10 (C) Malocclusion deviating from a normal occlusal
11 relationship that cannot reasonably be corrected by nonsurgical
12 means such as orthodontics or prosthetics. This item is
13 applicable only as evidence for indication of surgical
14 treatment.
15 (D) Inability to open or close the jaw adequately based on
16 medically accepted range of motion standards. These ranges are
17 as follows: forty-eight (48) to fifty-two (52) millimeters
18 vertical and twelve (12) to fourteen (14) millimeters lateral.
19 Adherence to these measurements is recommended. Any deviation
20 should be justified in a report as part of the evidence.
21 (E) A patient history, including the patient's perception of
22 pain, dysfunction and the impact on the patient's quality of
23 life.
24 (iv) The following data shall be submitted so that claims
25 may be evaluated appropriately:
26 (A) A narrative of the patient's clinical condition in
27 conjunction with the Temporomandibular Joint Dysfunction
28 Nonsurgical or Surgical Treatment Preauthorization Form.
29 (B) Mounted study models with appropriate centric record and
30 transcranial x-ray or preferably a corrected tomography. This
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1 data may be substituted with appropriate paper documentation
2 using current United States Food and Drug Administration-
3 approved computer imaging systems, for example, MRI, that have
4 the ability to photograph all necessary information.
5 (j) This section shall not be construed to affect any other
6 coverage required under the acts under subsection (a) or to
7 restrict the scope of coverage under any policy, contract or
8 certificate issued or delivered in this Commonwealth to any
9 individual or group.
10 (k) Nothing in this section shall be construed to encourage
11 surgical procedures over appropriate nonsurgical procedures.
12 (l) As used in this section, the term "functional deformity"
13 means a deformity of the bone or joint structure of the maxilla
14 or mandible such that the normal character and essential
15 function of such bone structure is impeded. A "temporomandibular
16 joint" means the connection of the mandible and the temporal
17 bone through the articular disc surrounded by the joint capsule
18 and associated ligaments and tendons. "Temporomandibular joint
19 dysfunction" means congenital or developed anomalies of the
20 temporomandibular joint. An "emergency" means a condition in
21 which immediate medical care is necessary to prevent serious
22 impairment or the death of the individual.
23 Section 2. This act shall take effect in 60 days.
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