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Download TN Wisdom Teeth 100 - UHCRiverValley.com
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Impacted Wisdom Teeth Rider UnitedHealthcare Plan of the River Valley, Inc. Impacted Wisdom Teeth Rider At-A-Glance Covered Services are payable by UnitedHealthcare at 100% of the allowed charge. Coinsurance does not apply toward the applicable medical maximum out-of-pocket expense. Services must be provided by an oral surgeon who is a participating provider. Benefits will be payable only if such services are medically necessary. Benefit Features Covered Services Oral evaluation and diagnostic consultation • Removal of impacted wisdom tooth - soft tissue • Removal of impacted wisdom tooth - partially bony • Removal of impacted wisdom tooth - completely bony • Removal of impacted wisdom tooth completely bony with unusual surgical complications • Intravenous sedation • X-ray (Periapical 1st film, Panorex x-ray) Benefit Exclusions Alveoloplasty • Bitewing x-rays • Charges for failure to keep a scheduled visit • Experimental services/procedures • Hardware/ appliances • Major dental services • Non-intravenous conscious sedation (nitrous oxide) • Orthodontic services • Periodontics • Preventive and diagnostic dental services • Sealants • Services solely cosmetic in nature • Simple tooth extraction • Temporomandibular Joint Syndrome • With the exception of the covered services listed above, any primary dental services JDHP TN Wisdom Teeth Rider 10-04 UnitedHealthcare Plan of the River Valley, Inc. Wisdom 100
