Download Dental Exclusions

EXCLUSIONS
A charge for the following is not covered:
(1)
Administrative costs. Administrative costs of completing claim forms or reports or for providing
dental records.
(2)
Appliances. Items intended for sport or home use, such as athletic mouthguards or habit-breaking
appliances.
(3)
Broken appointments. Charges for broken or missed dental appointments.
(4)
Congenital or Developmental Conditions. Treatment of congenital (hereditary) or developmental
(following birth) malformations, unless expressly included.
(5)
Cosmetic Dentistry. Treatment rendered for cosmetic purposes.
NOTE: Excess charges for a veneer or facing (i.e., a “tooth-colored” exterior) on a crown or pontic
or a tooth-colored restoration is not covered on a tooth posterior to the second bicuspid but will be
considered “cosmetic”. The maximum allowance will be the allowance for the least costly restoration
which will provide a functional result.
(6)
Crowns. Crowns for teeth that are restorable by other means or for the purpose of Periodontal
Splinting.
(7)
Customized Prosthetics. Precision or semi-precision attachments, overdentures, or customized
prosthetics.
(8)
Discoloration Treatment. Teeth whitening or any other treatment to remove or lessen
discoloration, except in connection with endodontia.
(9)
Excess Care. Services which exceed those necessary to achieve an acceptable level of dental
care. If it is determined that alternative procedures, services, or courses of treatment could be
(could have been) performed to correct a dental condition. Plan benefits will be limited to the least
costly procedure(s) which would produce a professionally satisfactory result.
Duplicate prosthetic devices or appliances.
(10)
Excluded under Medical. Services that are excluded under Medical Plan Exclusions.
(11)
Experimental Procedures. Services which are considered experimental or which are not approved
by the American Dental Association.
(12)
Fluoride Treatments.
(13)
Hospital Expenses
(14)
Hygiene. Oral hygiene, plaque control programs or dietary instructions.
(15)
Implants. Implants, including any appliances and/or crowns and the surgical insertion or removal of
implants.
(16)
Medical services. Services that, to any extent, are payable under any medical expense benefits of
the Plan.
(17)
Myofunctional Therapy. Muscle training therapy or training to correct or control harmful habits.
(18)
No listing. Services which are not included in the list of covered dental services.
(19)
Non-Professional Care. Services rendered by someone other than:
a dentist (D.D.S. or D.M.D.);
a dental hygienist, X-ray technician or other qualified technician who is under the supervision of a
dentist; or
a Physician furnishing dental services for which he is licensed.
(20)
Oral Hygiene Counseling, Etc. Education or training in and supplies used for dietary or nutritional
counseling, personal oral hygiene instruction or plaque control. Charges for supplies normally used
at home, including but not limited to toothpaste, toothbrushes, waterpiks, and mouthwashes.
(21)
Orthodontia. Orthodontic treatment and orthognathic surgery.
(22)
Orthognathic Surgery.
(23)
Personalization. Personalization of dentures.
(24)
Prescription Drugs. See “Prescription Drugs, Outpatient” in the Medical Benefit Summary.
(25)
Prior to Effective Date / After Termination Date. Courses of treatment which were begun prior to
the Covered Person’s effective date, including crowns, bridges or dentures which were ordered prior
to the effective date.
(26)
Replacement. Replacement of lost or stolen appliances.
(27)
Space Maintainers.
(28)
Splinting. Crowns, fillings or appliances that are used to connect (splint) teeth, or change or alter
the way the teeth meet, including altering the vertical dimension, restoring the bite (occlusion) or are
cosmetic.
(29)
Temporary Restorations and Appliances. Excess charges for temporary restorations and
appliances. The Eligible Expenses for the permanent restoration or appliance will be the maximum
covered charge.
(30)
TMJ / Jaw Joint Treatment. Any charges for jaw (mandibular) augmentation or reduction
procedures; or procedures, restorations or appliances for the treatment or for the prevention of
temporomandibular joint dysfunction syndrome.