| (1) |
Examination and
prophylaxis, including scaling and polishing is
limited to once every six(6) months. |
(17) |
Post and Cores (ADA
Codes 2952 and 2954) will be covered
only for teeth that have had root canal therapy. |
| (2) |
Coverage is limited
to those services set forth in the Schedule
of Covered Procedures. If a service is not
listed, it is not
included. |
(18) |
Gingivectomy/gingivoplasty
and osseous surgery (ADA Codes
4210, 4211, 4260, 4261) once per quadrant per
[thirty-six (36)
month period]. |
| (3) |
Benefits for
prophylaxis (ADA Code 1110) will not be paid if
performed on the same date of service with
periodontal
cleaning treatment. (ADA Code 4355, 4910, 4341,
4342.) |
(19) |
Retreatments,
Relines, Rebases, Replacements, or Repairs are
excluded within [six (6) months] of the
completion of the initial
procedure. [Benefits for denture repair will be
limited to no
more than half the cost of the Provider fee for
a new denture.] |
| (4) |
Bitewing x-rays are
limited to once every [twelve (12) months],
limited to four (4) bitewings. |
(20) |
Relines and rebases
of existing removable dentures no more
than once per [thirty-six (36) month period]. |
| (5) |
Full mouth x-rays
(ADA Code 0210) or panoramic x-rays (ADA
Code 0330) are limited to once every [sixty (60)
months],
except when taken for diagnosis of 3rd molars,
cysts, or
neoplasms. |
(21) |
Interim complete
dentures (ADA Codes 5810, 5811) and interim
partial dentures (ADA Codes 5820, 5821) may not
be replaced
for a [twelve (12) month period]. |
| (6) |
Consultation (ADA
Code 9310) performed by a Specialist will
not be paid if the dental procedure is performed
on the same
date of service by that Specialist. Consultation
should already
be included with the dental procedure. |
(22) |
Deep sedation (ADA
Codes 9220, 9221) must be performed by
an Oral Surgeon. |
| (7) |
For Eligible
Dependents (age [14] and under) fluoride once
every [twelve (12) months]. |
(23) |
Examination,
evaluation and treatment of temporomandibular
joint (TMJ) pain dysfunction is excluded. |
| (8) |
Sealants for
Eligible Dependents (age [14] and under) once
per
1st and 2nd permanent molar once per tooth per
lifetime. |
(24) |
Replacement of all
teeth and acrylic on cast metal framework
(ADA Codes 5670, 5671) limited to once per
[thirty-six (36)
month] period. |
| (9) |
Space maintainers
(ADA Codes 1510, 1515, 1520, 1525) for
Eligible Dependents (age [14] and under) once
per lifetime per
space. |
(25) |
Palliative
treatment (ADA Code 9110) will be covered as a
separate benefit only if no other service other
than exam and
radiographs were done during the visit. |
| (10) |
Periodontal scaling
and root planning (ADA Codes 4341 and
4342) is limited to once per quadrant every
[twenty-four (24)
months]. In order to receive benefits, the
Covered Person must
submit to DeneX Dental, before treatment, a copy
of the
periodontal chart for pre-authorization for
documented
periodontal disease which must include at least
four (4) teeth
per quadrant with 4 millimeters or greater
periodontal pockets. |
(26) |
Internal bleaching
of a tooth (ADA Code 9974) will only be
covered if the tooth had root canal treatment. |
| (11) |
Periodontal
maintenance (ADA Code 4910) limited to two per
[twelve (12) month period] following active
periodontal
treatment (excluding gross debridement – ADA
Code 4355). |
(27) |
Dental procedures
begun prior to the Covered Person’s
effective date of coverage are excluded for
[twelve (12) months]
following the Covered Person’s effective date.
Examples
include, but are not limited to, teeth prepared
for crowns, root
canal therapy in progress. This exclusion does
not apply to
Diagnostic & Preventive Services. |
| (12) |
Full mouth gross
debridement (ADA Code 4355) limited to once
per [thirty six (36) months]. |
(28) |
Replacement of
missing natural teeth, lost prior to the Covered
Person’s effective date, are excluded for
[twelve months]
following the Covered Person’s effective date. |
| (13) |
Resin based
composites of posterior teeth (ADA Codes 2391 to
2394) will be paid at the rate for Amalgams. The
Covered
Person is responsible for any difference in fees
charged by the
Provider. |
(29) |
Hospitalization for
any dental procedure is excluded. |
| (14) |
Amalgams and
Composites (ADA Codes 2140 to 2394) one
restoration allowed per surface every [thirty
six (36) months]. |
(30) |
Drugs obtainable
with or without a prescription are excluded. |
| (15) |
Dentures, Bridges,
Crowns (per tooth) are limited to once every
[seven (7) years]. |
(31) |
Where two or more
professionally acceptable dental treatments
for a dental condition exist, the Plan bases
reimbursement on
the least costly treatment alternative. |
| (16) |
Root canals (ADA
Codes 3310, 3320, 3330) once per tooth per
lifetime. Re-treatment of root canal is limited
to not more than
once in [twenty four (24) months] for the same
tooth. |
|
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