PRIOR PRINTER'S NO. 1256 PRINTER'S NO. 3691
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, EGOLF, PETRARCA, L. I. COHEN AND
SEYFERT, APRIL 2, 1997
AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF
REPRESENTATIVES, AS AMENDED, JUNE 8, 1998
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 633 634. Coverage for Treatment of Temporomandibular <--
21 Joint Dysfunction and Surgery, if Medically Necessary, for
1 Deformities of the Maxilla or Mandible.--(a) (1) This section <--
2 shall apply to any individual or group health, sickness or
3 accident policy or subscriber contract or certificate issued by
4 any entity subject to 40 Pa.C.S. Ch. 61 (relating to hospital
5 plan corporations) or 63 (relating to professional health
6 service plan corporation), this act, the act of December 29,
7 1972 (P.L.1701, No.364), known as the "Health Maintenance
8 Organization Act," or the act of December 14, 1992 (P.L.835,
9 No.134), known as the "Fraternal Benefit Societies Code," which
10 provides hospital or medical/surgical coverage.
11 (2) NOTHING IN THIS SECTION SHALL APPLY TO ACCIDENT ONLY, <--
12 SPECIFIED DISEASE, HOSPITAL INDEMNITY, MEDICARE SUPPLEMENT,
13 LONG-TERM CARE OR OTHER LIMITED BENEFIT HEALTH INSURANCE
14 POLICIES.
15 (b) If an insurance policy, contract or certificate provides
16 coverage for benefits to a resident of this Commonwealth, it
17 shall be deemed to be delivered in this Commonwealth, regardless
18 of whether the insurer issuing or delivering the policy is
19 located within or outside of this Commonwealth.
20 (c) No policy may be issued for delivery in this
21 Commonwealth which:
22 (1) excludes medically necessary nonsurgical or surgical
23 treatment for temporomandibular joint dysfunction by
24 professionals qualified by education, training and experience;
25 or
26 (2) excludes medically necessary surgery for the treatment
27 of functional deformities of the maxilla and mandible.
28 (d) The provisions of this section shall not cover cosmetic
29 or elective orthodontic or periodontal care or general dental
30 care.
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1 (e) Nothing in subsection (c)(1) and (2) shall be construed
2 to prevent the application of the deductible, co-insurance or
3 pre-existing condition limitation contained in the policy,
4 contract or certificate.
5 (f) A definition of pre-existing condition does not prohibit
6 an insurer from using an application form designed to elicit the
7 complete health history of the applicant, and on the basis of
8 the answers on that application, from underwriting in accordance
9 with that insurer's established underwriting standards. Unless
10 otherwise provided in the policy, contract or certificate, a
11 pre-existing condition need not be covered until the waiting
12 period is satisfied, as indicated in the policy, contract or
13 certificate. No policy, contract or certificate may exclude or
14 use waivers or riders of any kind to exclude, limit or reduce
15 coverage or benefits for specifically named or described pre-
16 existing diseases or physical conditions beyond the waiting
17 period described in the policy, contract or certificate.
18 (g) Policies, contracts or certificates shall contain a
19 twenty-five thousand dollar ($25,000) lifetime maximum for
20 nonsurgical procedures. The lifetime maximum of the policy shall
21 be applied to surgical procedures. The twenty-five thousand
22 dollar ($25,000) lifetime maximum for nonsurgical procedures
23 does not prevent the company from exercising the option to grant
24 additional benefits for nonsurgical procedures if it is more
25 cost effective than providing benefits for surgery.
26 (h) Ninety (90) days after a nonsurgical procedure, the
27 provider of treatment is required to provide documentation and a
28 narrative, signed by the patient, to the insurer showing the
29 progress of the insured. If the documentation and narrative do
30 not show satisfactory progress, benefits are terminated until a
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1 second opinion is received. If the second opinion differs from
2 the treating provider, a revised treatment plan is required. If
3 the second opinion, due to a valid reason, does not differ from
4 the current treatment, the current treatment shall be continued
5 for an additional ninety (90) days at which time the treatment
6 plan will be re-evaluated.
7 (i) Insurers shall require preauthorization for coverage,
8 and providers of treatment shall use a uniform preauthorization
9 request form and follow certain standards which include
10 evidence-based standards and patient-centered standards in
11 determining whether treatment is medically necessary. The
12 following apply:
13 (1) An insurer shall require a preauthorization for
14 nonsurgical treatment, and the provider of treatment shall
15 submit a properly completed Temporomandibular Joint Dysfunction
16 Nonsurgical Treatment Preauthorization Request Form.
17 (2) An insurer shall require a preauthorization for surgical
18 treatment for coverage, and the provider of treatment shall
19 submit a properly completed Temporomandibular Joint Dysfunction
20 Surgical Treatment Preauthorization Request Form.
21 (3) In cases of emergency, the preauthorization form shall
22 be submitted no later than forty-eight (48) hours after the
23 emergency treatment. Providers are permitted only two (2)
24 emergencies with the same patient within one (1) week without
25 preauthorization prior to treatment providing the
26 preauthorization is submitted no later than forty-eight (48)
27 hours after the emergency treatment.
28 (4) The following are standards and requirements for
29 evaluation of claims for temporomandibular dysfunction for
30 medical necessity:
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1 (i) To evaluate appropriately a claim for treatment of this
2 disorder, the existence of a skeletal and/or muscular
3 dysfunction shall be documented.
4 (ii) Any maldevelopment that is not treatable with
5 conventional, reversible, nonsurgical treatment, yielding a
6 stable and functional post-treatment occlusion without worsening
7 the patient's original condition, shall be a covered surgical
8 procedure.
9 (iii) Indications for nonsurgical and PROCEDURES IN EXCESS <--
10 OF TWO HUNDRED DOLLARS ($200) AND ALL surgical treatments shall
11 include evidence of the following:
12 (A) Physical evidence of musculoskeletal, dento-osseous or
13 soft tissue deformity.
14 (B) Imaging evidence of musculoskeletal, dento-osseous or
15 soft tissue deformity.
16 (C) Malocclusion deviating from a normal occlusal
17 relationship that cannot reasonably be corrected by nonsurgical
18 means such as orthodontics or prosthetics. This item is
19 applicable only as evidence for indication of surgical
20 treatment.
21 (D) Inability to open or close the jaw adequately based on
22 medically accepted range of motion standards. These ranges are
23 as follows: forty-eight (48) to fifty-two (52) millimeters
24 vertical and twelve (12) to fourteen (14) millimeters lateral.
25 Adherence to these measurements is recommended. Any deviation
26 should be justified in a report as part of the evidence.
27 (E) A patient history, including the patient's perception of
28 pain, dysfunction and the impact on the patient's quality of
29 life.
30 (iv) The following data shall be submitted so that claims
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1 may be evaluated appropriately:
2 (A) A narrative of the patient's clinical condition in
3 conjunction with the Temporomandibular Joint Dysfunction
4 Nonsurgical or Surgical Treatment Preauthorization Form.
5 (B) Mounted study models with appropriate centric record and
6 transcranial x-ray or preferably a corrected tomography. This
7 data may be substituted with appropriate paper documentation
8 using current United States Food and Drug Administration-
9 approved computer imaging systems, for example, MRI, that have
10 the ability to photograph all necessary information.
11 (j) This section shall not be construed to affect any other
12 coverage required under the acts under subsection (a) or to
13 restrict the scope of coverage under any policy, contract or
14 certificate issued or delivered in this Commonwealth to any
15 individual or group.
16 (k) Nothing in this section shall be construed to encourage
17 surgical procedures over appropriate nonsurgical procedures.
18 (l) As used in this section, the term "functional deformity"
19 means a deformity of the bone or joint structure of the maxilla
20 or mandible such that the normal character and essential
21 function of such bone structure is impeded. A "temporomandibular
22 joint" means the connection of the mandible and the temporal
23 bone through the articular disc surrounded by the joint capsule
24 and associated ligaments and tendons. "Temporomandibular joint
25 dysfunction" means congenital or developed anomalies of the
26 temporomandibular joint. An "emergency" means a condition in
27 which immediate medical care is necessary to prevent serious
28 impairment or the death of the individual.
29 Section 2. This act shall take effect in 60 days.
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