Page 58 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Non-surgical treatment including:
• Clinical exams.

• Oral appliances (orthotic splints).
• Arthrocentesis.

• Trigger-point injections.
Benefits are provided for surgical treatment if the following criteria are met:

• There is radiographic evidence of joint abnormality.
• Non-surgical treatment has not resolved the symptoms.

• Pain or dysfunction is moderate or severe.
Benefits for surgical services include:

• Arthrocentesis.
• Arthroscopy.

• Arthroplasty.

• Arthrotomy.
• Open or closed reduction of dislocations.
Benefits for surgical services also include FDA-approved TMJ prosthetic replacements when all other
treatment has failed.

Therapeutic Treatments - Outpatient
Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a
Physician's office, including:

• Dialysis (both hemodialysis and peritoneal dialysis).
• Intravenous chemotherapy or other intravenous infusion therapy.

• Radiation oncology.
Covered Health Care Services include medical education services that are provided on an outpatient
basis at a Hospital or Alternate Facility by appropriately licensed or registered health care professionals
when both of the following are true:

• Education is required for a disease in which patient self-management is a part of treatment.
• There is a lack of knowledge regarding the disease which requires the help of a trained health
professional.
Benefits include:

• The facility charge and the charge for related supplies and equipment.
• Physician services for anesthesiologists, pathologists and radiologists. Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.

55 Section 1: Covered Health Care Services