Download Pediatric Dental Rider

PEDIATRIC DENTAL BENEFITS RIDER
As described in this Rider, the Certificate of Coverage is revised as stated below. This Rider is
applicable to Certificates of Coverage issued in the State of Ohio.
Any provision of this Rider in conflict with the requirements of state or federal statutes or
regulations (of the jurisdiction in which the Rider is delivered) is hereby amended to conform to
the minimum requirements of such statutes and regulations.
If this rider is attached, it supersedes the Pediatric dental benefits and exclusions shown in the
Certificate of Coverage.
All terms used herein have the same meaning given to them in the Certificate of Coverage, unless
otherwise specifically defined herein.
PHP-IND-OH-HMO-PDR-2017
Schedule of Benefits
Covered expenses for pediatric dental care apply toward Your Deductible, Coinsurance, or
Out-of-Pocket Limit.
Covered Dental Caetgory
Plan Pays for Services From
Network Providers
Class A (Basic) Services
0% after Deductible
Class B (Intermediate) Services
30% after Deductible
Class C (major) Services
50% after Deductible
Class D (Orthodontic) Services
50% after Deductible
-2-
DEFINITIONS
Dental Emergency — A sudden, serious dental condition caused by an accident or dental disease
that, if not treated immediately, would result in serious harm to the dental health of the Pediatric
Member.
Palliative Dental Care — Treatment used in a Dental Emergency to relieve, ease, or alleviate the
acute severity of dental pain, swelling, or bleeding. Palliative dental care treatment usually is
performed for, but is not limited to, the following acute conditions:
1.
2.
3.
4.
Toothache;
Localized infection;
Muscular pain; or
Sensitivity and irritations of the soft tissue
Services are not considered palliative dental care when used with any other Pediatric Dental
Services, except x-rays and/or exams
Pediatric Clinical Review — The review of required/submitted documentation by a Dentist for
the determination of pediatric Dental Services.
Pediatric Dental Services — Includes the following services:
1. Ordered by a Dentist;
2. Described in the “Pediatric Dental Care” section of this rider; and
3. Incurred when the Pediatric Member is insured for that benefit under this
policy/certificate on the expensive incurred date.
Pediatric Member — A member who is under the age of 19.
THE FOLLOWING PEDIATRIC DENTAL BENEFIT IS ADDED TO THE
“BENEFITS” SECTION:
Pediatric Dental Benefits
Covered Services include Pediatric Dental Services for Pediatric Member(s). Pediatric Dental
Services include the following dental services as categorized below. Coverage for a Dental
Emergency is limited to Palliative Dental Care only.
Class A (Basic) Services:
Dental
Code
D1120
D1208
D1351
D1352
D1510
D1515
D1520
D1525
Description of Service
Preventative Services
Prophylaxis – Child – Limited to 1 every 6 months
Topical application of fluoride (excluding prophylaxis) – 2 every 12 months
Sealant – per tooth – unrestored permanent molars – 1 sealant per tooth every 36 months
Preventative resin restorations in a moderate to high caries risk patient – permanent
tooth – 1 sealant per tooth every 36 months
Space maintainer – fixed – unilateral
Space maintainer – fixed - bilateral
Space maintainer – removable - unilateral
Space maintainer – removable - bilateral
-3-
D1550
Re-cementation of space maintainer
Diagnostic and Treatment Services
D0120
Periodic oral evaluation – Limited to 1 every 6 months
D0140
Limited oral evaluation
D0150
Comprehensive oral evaluation – Limited to 1 every 6 months
D0180
Comprehensive periodontal evaluation – Limited to 1 every 6 months
D0210
Intraoral – complete set of radiographic images including bitewings – 1 every 60 months
D0220
Intraoral – periapical radiographic image
D0230
Intraoral – additional periapical image
D0240
Intraoral – occlusal radiographic image
D0270
Bitewing – single image – 1 set every 6 months
D0272
Bitewings – two images – 1 set every 6 months
D0274
Bitewings – four images – 1 set every 6 months
D0277
Vertical Bitewings – 7 to 8 images – 1 set every 6 months
D0330
Panoramic radiographic image – 1 image every 60 months
D0340
Cephalometric radiographic image
D0350
Oral / Facial Photographic images
D0391
Interpretation of Diagnostic Image
D0470
Diagnostic Models
Additional Procedures covered as Basic Services
D9110
Palliative treatment of dental pain – minor procedure
Services Not Covered (refer to “Limits and Exclusions” section for a list of General
Exclusions
D0320
TMJ arthrogram
D0321
Other TMJ images, by report
D0322
Tomographic survey
D0416
Viral culture
D0418
Analysis of saliva example chemical or biological analysis of saliva for diagnostic
purposes
D0425
Caries test
D0431
Adjunctive pre-diagnosis test
D0475
Declassification procedure
D0476
Special stains for microorganisms
D0477
Special stains not for microoganisms
D0478
Immunohistochemical stains
D0479
Tissue in-situ-hybridization
D0481
Electron microscopy
D0482
Direct immunofluorescence
D0483
In-direct immunofluorescence
D0484
Consultation on slides prepared elsewhere
D0485
Consultation including preparation of slides
D0486
Accession Transepithelial
D1310
Nutritional counseling
D1320
Tobacco counseling
D1330
Oral Hygiene Instruction
D1555
Removal of fixed space maintainer
Class B (Intermediate) Services:
-4-
Dental
Code
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2910
D2920
D2929
D2930
D2931
D2940
D2951
D3220
D3222
D3230
D3240
D4341
D4342
D7921
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
Description of Service
Minor Restorative Services
Amalgam – one surface, primary or permanent
Amalgam – two surfaces, primary or permanent
Amalgam – three surfaces, primary or permanent
Amalgam – four or more surfaces, primary or permanent
Resin-based composite – one surface, anterior
Resin-based composite – two surfaces, anterior
Resin-based composite – three surfaces, anterior
Resin-based composite – four or more surfaces or involving incisal angle (anterior)
Re-cement inlay
Re-cement crown
Prefabricated porcelain crown – primary – Limited to 1 every 60 months
Prefabricated stainless steel crown – primary tooth
Prefabricated stainless steel crown – permanent tooth
Protective Restoration
Pin retention - per tooth, in addition to restoration
Endodontic Services
Therapeutic pulpotomy (excluding final restoration) - If a root canal is within 45 days of the
pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal
procedure and benefits are not payable separately.
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development If a
root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is
considered a part of the root canal procedure and benefits are not payable separately.
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) - Limited
to primary incisor teeth for members up to age 6 and for primary molars and cuspids up to age
11 and is limited to once per tooth per lifetime
Pulpal therapy (resorbable filling) - posterior, primary tooth excluding final restoration). Incomplete
endodontic treatment when you discontinue treatment. - Limited to primary incisor teeth for
members up to age 6 and for primary molars and cuspids up to age 11 and is limited to once per
tooth per lifetime
Periodontal Services
Periodontal scaling and root planning-four or more teeth per quadrant – Limited to 1 every 24
months
Periodontal scaling and root planning-one to three teeth, per quadrant – Limited to 1 every 24
months
Collect - Apply Autologous Product - Limited to 1 in 36 months
Prosthodontic Services
Adjust complete denture – maxillary
Adjust complete denture – mandibular
Adjust partial denture – maxillary
Adjust partial denture - mandibular
Repair broken complete denture base
Replace missing or broken teeth - complete denture (each tooth)
Repair resin denture base
Repair cast framework
Repair or replace broken clasp
Replace broken teeth - per tooth
Add tooth to existing partial denture
-5-
D5660
D5710
Add clasp to existing partial denture
Rebase complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5720
Rebase maxillary partial denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5721
Rebase mandibular partial denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5730
Reline complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5731
Reline complete mandibular denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5740
Reline maxillary partial denture - Limited to 1in a 36-month period 6 months after the initial
installation
D5741
Reline mandibular partial denture - Limited to 1 in a 36-month period 6 months after the initial
installation
D5750
Reline complete maxillary denture (laboratory) – Limited to 1 in a 36-month period 6 months after
the initial installation
D5751
Reline complete mandibular denture (laboratory) - Limited to 1 in a 36-month period 6 months after
the initial installation
D5760
Reline maxillary partial denture (laboratory) - Limited to 1 in a 36-month period 6 months after the
initial installation
D5761
Reline mandibular partial denture (laboratory) Rebase/Reline - Limited to 1 in a 36-month period 6
months after the initial installation
D5850
Tissue conditioning (maxillary)
D5851
Tissue conditioning (mandibular)
D6930
Re-cement fixed partial denture
D6980
Fixed partial denture repair, by report
Oral Surgery
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone
and/or section of tooth
D7220
Removal of impacted tooth - soft tissue
D7230
Removal of impacted tooth – partially bony
D7240
Removal of impacted tooth - completely bony
D7241
Removal of impacted tooth - completely bony with unusual surgical complications
D7250
Surgical removal of residual tooth roots (cutting procedure)
D7251
Coronectomy - intentional partial tooth removal
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7280
Surgical access of an unerupted tooth
D7310
Alveoloplasty in conjunction with extractions - per quadrant
D7311
Alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant
D7320
Alveoloplasty not in conjunction with extractions - per quadrant
D7321
Alveoloplasty not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant
D7471
Removal of exostosis
D7510
Incision and drainage of abscess - intraoral soft tissue
D7910
Suture of recent small wounds up to 5 cm
D7953
Bone replacement graft for ridge preservation-per site
D7971
Excision of pericoronal gingiva
Services Not Covered (refer to “Limits and Exclusions” section for a list of General
Exclusions
D7292
Surgical replacement screw retained
-6-
D7293
D7294
D7880
D7899
D7951
D7952
D7997
D7998
Surgical replacement w/surgical flap
Surgical replacement without the surgical flap
TMJ Appliance
TMJ Therapy
Sinus Augmentation – Lateral
Sinus Augmentation of Vertical
Appliance Removal
Intraoral placement of a fixation device
Class C (Major) Services:
Dental
Code
D0160
D2510
Description of Service
Major Restorative Services
Detailed and extensive oral evaluation - problem focused, by report
Inlay - metallic – one surface – An alternate benefit will be provided
D2752
D2780
D2781
D2783
D2790
D2791
D2792
D2794
D2950
D2954
D2980
D2981
D2982
D2983
D2990
Inlay - metallic – two surfaces – An alternate benefit will be provided
Inlay - metallic – three surfaces – An alternate benefit will be provided
Onlay - metallic - two surfaces – Limited to 1 per tooth every 60 months
Onlay - metallic - three surfaces – Limited to 1 per tooth every 60 months
Onlay - metallic - four or more surfaces – Limited to 1 per tooth every 60 months
Crown - porcelain/ceramic substrate - Limited to 1 per tooth every 60 months
Crown - porcelain fused to high noble metal - Limited to 1 per tooth every 60 months
Crown - porcelain fused to predominately base metal – Limited to 1 per tooth every 60
months
Crown - porcelain fused to noble metal – Limited to 1 per tooth every 60 months
Crown - 3/4 cast high noble metal – Limited to 1 per tooth every 60 months
Crown - 3/4 cast predominately base metal – Limited to 1 per tooth every 60 months
Crown - 3/4 porcelain/ceramic – Limited to 1 per tooth every 60 months
Crown - full cast high noble metal– Limited to 1 per tooth every 60 months
Crown - full cast predominately base metal – Limited to 1 per tooth every 60 months
Crown - full cast noble metal– Limited to 1 per tooth every 60 months
Crown – titanium– Limited to 1 per tooth every 60 months
Core buildup, including any pins– Limited to 1 per tooth every 60 months
Prefabricated post and core, in addition to crown– Limited to 1 per tooth every 60 months
Crown repair, by report
Inlay Repair
Onlay Repair
Veneer Repair
Resin infiltration/smooth surface - Limited to 1 in 36 months
D3310
D3320
Endodontic Services
Anterior root canal (excluding final restoration)
Bicuspid root canal (excluding final restoration)
D2520
D2530
D2542
D2543
D2544
D2740
D2750
D2751
D3330
D3346
D3347
D3348
D3351
D3352
Molar root canal (excluding final restoration)
Retreatment of previous root canal therapy-anterior
Retreatment of previous root canal therapy-bicuspid
Retreatment of previous root canal therapy-molar
Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root
resorption, etc.)
Apexification/recalcification – interim medication replacement (apical closure/calcific repair of
perforations, root resorption, etc.)
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D3353
D3354
D3410
D3421
D3425
D3426
D3450
D3920
D4210
D4211
D4212
D4240
D4241
D4249
D4260
D4261
D4263
D4270
D4273
D4275
D4277
D4278
D4355
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
Note:
D6010
D6012
D6040
D6050
Apexification/recalcification - final visit (includes completed root canal therapy, apical
closure/calcific repair of perforations, root resorption, etc.)
Pulpal regeneration (completion of regenerative treatment in an immature permanent tooth
with a necrotic pulp) does not include final restoration
Apicoectomy/periradicular surgery - anterior
Apicoectomy/periradicular surgery - bicuspid (first root)
Apicoectomy/periradicular surgery - molar (first root)
Apicoectomy/periradicular surgery (each additional root)
Root amputation - per root
Hemisection (including any root removal) - not including root canal therapy
Periodontal Services
Gingivectomy or gingivoplasty – four or more teeth - Limited to 1 every 36 months
Gingivectomy or gingivoplasty – one to three teeth - Limited to 1 every 36 months
Gingivectomy or gingivoplasty - with restorative procedures, per tooth - Limited to 1
every 36 months
Gingival flap procedure, four or more teeth – Limited to 1 every 36 months
Gingival flap procedure, including root planning - one to three contiguous teeth or
tooth bounded spaces per quadrant – Limited to 1 every 36 months
Clinical crown lengthening-hard tissue
Osseous surgery (including flap entry and closure), four or more contiguous teeth or
bounded teeth spaces per quadrant – Limited to 1 every 36 months
Osseous surgery (including flap entry and closure), one to three contiguous teeth or
bounded teeth spaces per quadrant – Limited to 1 every 36 months
Bone replacement graft - first site in quadrant - Limited to 1 every 36 months
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft procedures (including donor site surgery)
Soft tissue allograft - Limited to 1 every 36 months
Free soft tissue graft 1st tooth
Free soft tissue graft-additional teeth
Full mouth debridement to enable comprehensive evaluation and diagnosis – Limited
to 1 per lifetime
Prosthodontic Services
Complete denture - maxillary – Limited to 1 every 60 months
Complete denture - mandibular – Limited to 1 every 60 months
Immediate denture - maxillary – Limited to 1 every 60 months
Immediate denture - mandibular – Limited to 1 every 60 months
Maxillary partial denture - resin base (including any conventional clasps, rests and
teeth) – Limited to 1 every 60 months
Mandibular partial denture - resin base (including any conventional clasps, rests and
teeth) – Limited to 1 every 60 months
Maxillary partial denture - cast metal framework with resin denture base (including
any conventional clasps, rests and teeth)– Limited to 1 every 60 months
Mandibular partial denture - cast metal framework with resin denture base (including
any conventional clasps, rests and teeth) – Limited to 1 every 60 months
Removable unilateral partial denture-one piece cast metal (including clasps and
teeth) – Limited to 1 every 60 months
An implant is a covered procedure of the plan only if determined to be a dental necessity.
Endosteal Implant - 1 every 60 months
Surgical Placement of Interim Implant Body - 1 every 60 months
Eposteal Implant – 1 every 60 months
Transosteal Implant, Including Hardware – 1 every 60 months
-8-
D6053
D6054
D6055
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
D6077
D6078
D6079
D6080
D6090
D6091
D6095
D6100
D6101
D6102
D6103
D6104
D6190
D6210
Implant supported complete denture
Implant supported partial denture
Connecting Bar – implant or abutment supported - 1 every 60 months
Prefabricated Abutment – 1 every 60 months
Custom Abutment - 1 every 60 months
Abutment supported porcelain ceramic crown -1 every 60 months
Abutment supported porcelain fused to high noble metal - 1 every 60 months
Abutment supported porcelain fused to predominately base metal crown - 1 every 60
months
Abutment supported porcelain fused to noble metal crown - 1 every 60 months
Abutment supported cast high noble metal crown - 1 every 60 months
Abutment supported cast predominately base metal crown - 1 every 60 months
Abutment supported cast noble metal crown - 1 every 60 months
Implant supported porcelain/ceramic crown - 1 every 60 months
Implant supported porcelain fused to high metal crown - 1 every 60 months
Implant supported metal crown - 1 every 60 months
Abutment supported retainer for porcelain/ceramic fixed partial denture - 1 every 60
months
Abutment supported retainer for porcelain fused to high noble metal fixed partial
denture - 1 every 60 months
Abutment supported retainer for porcelain fused to predominately base metal fixed
partial denture - 1 every 60 months
Abutment supported retainer for porcelain fused to noble metal fixed partial denture
- 1 every 60 months
Abutment supported retainer for cast high noble metal fixed partial denture 1 every
60 months
Abutment supported retainer for predominately base metal fixed partial denture - 1
every 60 months
Abutment supported retainer for cast noble metal fixed partial denture - 1 every 60
months
Implant supported retainer for ceramic fixed partial denture - 1 every 60 months
Implant supported retainer for porcelain fused to high noble metal fixed partial
denture - 1 every 60 months
Implant supported retainer for cast metal fixed partial denture - 1 every 60 months
Implant/abutment supported fixed partial denture for completely edentulous arch - 1
every 60 months
Implant/abutment supported fixed partial denture for partially edentulous arch - 1
every 60 months
Implant Maintenance Procedures -1 every 60 months
Repair Implant Prosthesis -1 every 60 months
Replacement of Semi-Precision or Precision Attachment -1 every 60 months
Repair Implant Abutment - 1 every 60 months
Implant Removal - 1 every 60 months
Debridement periimplant defect, covered if implants are covered - Limited to 1 every
60 months
Debridement and osseous periimpant defect, covered if implants are covered Limited to 1 every 60 months
Bone graft periimplant defect, covered if implants are covered
Bone graft implant replacement, covered if implants are covered
Implant Index - 1 every 60 months
Pontic - cast high noble metal – Limited to 1 every 60 months
-9-
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6519
D6520
D6530
D6543
D6544
D6545
D6548
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D9940
Pontic - cast predominately base metal – Limited to 1 every 60 months
Pontic - cast noble metal– Limited to 1 every 60 months
Pontic – titanium – Limited to 1 every 60 months
Pontic - porcelain fused to high noble metal – Limited to 1 every 60 months
Pontic - porcelain fused to predominately base metal – Limited to 1 every 60 months
Pontic - porcelain fused to noble metal – Limited to 1 every 60 months
Pontic - porcelain/ceramic – Limited to 1 every 60 months
Inlay/onlay – porcelain/ceramic – Limited to 1 every 60 months
Inlay – metallic – two surfaces – Limited to 1 every 60 months
Inlay – metallic – three or more surfaces - Limited to 1 every 60 months
Onlay – metallic – three surfaces - 1 every 60 months
Onlay – metallic – four or more surfaces -1 every 60 months
Retainer - cast metal for resin bonded fixed prosthesis -1 every 60 months
Retainer - porcelain/ceramic for resin bonded fixed prosthesis -1 every 60 months
Crown - porcelain/ceramic - 1 every 60 months
Crown - porcelain fused to high noble metal - 1 every 60 months
Crown - porcelain fused to predominately base metal - 1 every 60 months
Crown - porcelain fused to noble metal - 1 every 60 months
Crown - 3/4 cast high noble metal - 1 every 60 months
Crown - 3/4 cast predominately base metal - 1 every 60 months
Crown - 3/4 cast noble metal - 1 every 60 months
Crown - 3/4 porcelain/ceramic - 1 every 60 months
Crown - full cast high noble metal - 1 every 60 months
Crown - full cast predominately base metal - 1 every 60 months
Crown - full cast noble metal - 1 every 60 months
Occlusal guard, by report
Services Not Covered (refer to “Limits and Exclusions” section for a list of
General Exclusions
D2410
D2420
D2430
D2799
D2955
D2970
D2975
D3460
D3470
D3910
D3950
D4230
D4231
D4320
D4321
D5810
D5811
D5820
D5821
D5862
D5867
D5986
Gold Foil 1 surface
Gold Foil 2 surface
Gold Foil 3 surface
Provisional Crown
Post Removal
Temporary Crown
Coping
Endodontic Implant
Intentional reimplantation
Surgical procedure for isolation of tooth
Canal preparation
Anatomical crown exposure 4 or more teeth
Anatomical crown exposure 1-3 teeth
Splinting intracoronal
Splinting extracoronal
Complete denture upper (interim)
Complete denture lower (interim)
Partial denture upper (interim)
Partial denture lower (interim)
Precision Attachment
Replacement Precision Attachment
Fluoride Gel Carrier
- 10 -
D6051
D6199
D6253
D6793
D6920
D6940
D6950
D6975
Interim Abutment
Unspecified Implant Procedure, by report
Provisional Pontic
Provisional Retainer Crown
Connector bar
Stress breaker
Precision Attachment
Coping
Class D (Orthodontic) Services
Dental Description of Service
Code
Orthodontia Services – Dependent Child Age Limit is 19
D8010 Limited orthodontia treatment of the primary dentition
D8020
Limited orthodontia treatment of the transitional dentition
D8030
Limited orthodontic treatment of the adolescent dentition
D8050
Interceptive orthodontic treatment of the primary dentition
D8060
Interceptive orthodontic treatment of the transitional dentition
D8070
Comprehensive orthodontic treatment of the transitional dentition
D8080
Comprehensive orthodontic treatment of the adolescent dentition
D8090
Comprehensive orthodontic treatment of the adult dentition
D8210
Removable appliance therapy
D8220
Fixed appliance therapy
D8660
Pre-orthodontic treatment visit
D8670
Periodic orthodontic treatment visit (as part of contract)
D8680
Orthodontic retention (removal of appliances, construction and placement of
retainer(s)
Services Not Covered (refer to “Limits and Exclusions” section for a list of General
Exclusions
Orthodontic care for dependent children age 19 and over
Repair of damaged orthodontic appliances
Replacement of lost or missing appliance
Services to alter vertical dimension and/or restore or maintain the occlusion. Such
procedures include, but are not limited to, equilibration, periodontal splinting, full
mouth rehabilitation, and restoration for misalignment of teeth
General Services
Dental Code
D9220
D9221
D9241
D9242
Description of Service
Anesthesia Services
Deep sedation/general anesthesia – first 30 minutes
Deep sedation/general anesthesia – each additional 15 minutes
Intravenous Sedation
Intravenous conscious sedation/analgesia – first 30 minutes
Intravenous conscious sedation/analgesia – each additional 15 minutes
Consultations
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D9310
D9610
D9930
Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment)
Medications
Therapeutic drug injection, by report
Post Surgical Services
Treatment of complications (post-surgical) unusual circumstances, by report
Integral Services
Integral services are added charges related to materials or equipment used in the delivery of dental
care.
The following services are considered integral to the dental service and will not be paid
separately:
• Local anesthetics
• Bases
• Pulp testing
• Pulp caps
• Treatment plans
• Occlusal (biting or grinding surfaces of molar and bicuspid teeth) adjustments
• Nitrous oxide
• Irrigation
• Tissue preparation associated with impression or placement of a restoration]
Pretreatment Plan
We suggest that if dental treatment is expected to exceed $300, the dentist should submit a
treatment plan for review before treatment begins. The treatment plan should include:
• A list of services to be done using the American Dental Association terms and codes
• The dentist’s written description of the proposed treatment for the pediatric member
• Pretreatment x-rays supporting the services to be done
• Itemized cost of the proposed treatment
• Any other applicable diagnostic materials that we may request
We will provide you or the pediatric member and the dentist with an estimate for benefits
payable based on the submitted plan. The estimate is not a guarantee of what we will pay. It tells
you or the pediatric member and the dentist in advance about the benefits payable for the
pediatric dental services in the plan. An estimate for services is not necessary for an emergency.
An estimate for services is valid for 90 days after the date we notify you and/or the pediatric
member and dentist of the benefits payable for the proposed plan. The estimate is subject to the
pediatric member’s eligibility of coverage. If treatment will not begin for more than 90 days after
the date we notify you and/or the pediatric member and the dentist, we require a new plan to be
submitted.
Alternative Services
- 12 -
If two or more services are valid to correct a dental condition, we will base the benefits payable
on the least expensive service that gives a professionally satisfactory result, as determined by us.
We will pay up to the plan allowance for the least costly pediatric dental service.
The service is subject to any applicable medical deductible, pediatric dental deductible, and/or
co-insurance. See the SOB section in this document for pediatric dental deductible and
coinsurance amounts. The member will be responsible for any amount in excess of the plan
allowance for the services performed. If you or the pediatric member and the dentist decide on a
more expensive service, payment will be limited to the plan allowance for the least costly service
and will be subject to any medical deductible, pediatric dental deductible, and coinsurance.
THE FOLLOWING PEDIATRIC DENTAL CARE EXCLUSION IS ADDED TO THE “LIMITS
AND EXCLUSIONS” SECTION:
What’s Not Covered
Unless specifically stated otherwise, no benefit will be provided for the following:
Any expense rising from the completion of forms
•
Any expense due to a member’s failure to keep an appointment
•
Any expense for a service we consider cosmetic, unless it is due to an accidental dental
injury
•
Expenses incurred for:
o Precision or semi-precision attachments
•
•
•
•
•
•
o
Overdentures and any endodontic treatment associated with overdentures
o
Other customized attachments
o
Any services for 3D image (cone beam images)
o
Temporary and interim dental services
o Extra charges related to materials or equipment used in the delivery of care
Charges by a family member or person who lives with the pediatric member
Any services related to:
o Changing vertical dimension of teeth or changing the spacing and/or shape of the
teeth
o
Restoration or maintenance of occlusion
o
Splinting teeth, including multiple abutments, or any service to stability of
periodontally-weakened teeth
o
Replacing tooth structures lost due to abrasion, attrition, erosion, or abfraction
o Bite registration or bite analysis
Infection control
Expenses incurred for services done by someone other than a dentist (exception for
scaling and teeth cleaning and the topical application of fluoride, which may be done by
a licensed dental hygienist)
o Treatment must be performed under supervision and guidance of a licensed dentist
in accordance with generally accepted standards
Any hospital, surgical, or treatment facility, or for services of an anesthesiologist or
anesthetist
Prescription drugs or pre-medications, whether dispensed or prescribed
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•
•
Any service that:
o Is not eligible for benefits based on the Pediatric Clinical Review
o
Does not offer a favorable prognosis
o
Does not have uniform professional acceptance
o Is deemed experimental or investigational in nature
Repair and replacement of orthodontic appliances
•
Preventive control programs such as oral hygiene instructions, plaque control, take-home
items, prescriptions, and dietary planning
•
Replacement of any lost, stolen, damaged, misplaced, or duplicate major restoration,
prosthesis or appliance
•
Any susceptibility testing, laboratory tests, saliva samples, anaerobic cultures, sensitivity
testing, or charges for oral pathology procedures
•
Services and treatment not prescribed by or under the direct supervision of a dentist,
except in those states where dental hygienists are allowed to practice without
supervision by a dentist. In these states, we will pay for eligible covered services
provided by an authorized dental hygienist performing within the scope of his or her
license and applicable state law;
•
Services and treatment for any illness or injury which occurs in the course of employment
if a benefit or compensation is available, in whole or in part, under the provision of any
law or regulation or any government unit. This exclusion applies whether or not you claim
the benefits or compensation;
•
Services and treatment received from a dental or medical department maintained by or
on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or
similar person or group;
•
Services and treatment performed before your effective date of coverage;
•
Services and treatment incurred after the termination date of your coverage unless
otherwise indicated;
•
Services and treatment which are not dentally necessary or which do not meet generally
accepted standards of dental practice.
•
Services and treatment resulting from your failure to comply with professionally
prescribed treatment;
•
Telephone consultations;
•
Any services that are considered strictly cosmetic in nature including, but not limited to,
charges for personalization or characterization of prosthetic appliances;
•
Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction
(TMD);
•
Services or treatment provided as a result of intentional self-inflicted injury or illness;
•
Services or treatment provided as a result of injuries suffered while committing or
attempting to commit a felony, engaging in an illegal occupation, or participating in a
riot, rebellion or insurrection;
•
Office infection control charges;
•
Charges for copies of your records, charts or x-rays, or any costs associated with sending
copies of your records, charts or x-rays;
•
State or territorial taxes on dental services performed;
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•
Those submitted by a dentist, which is for the same services performed on the same date
for the same member by another dentist;
•
Those provided free of charge by any governmental unit, except where this exclusion is
prohibited by law;
•
Those for which the member would not have an obligation to pay in the absence of this
or any similar coverage;
•
Those which are for specialized procedures and techniques;
•
Those performed by a dentist who is compensated by a facility for similar covered
services performed for members;
•
Duplicate, provisional and temporary devices, appliances, and services;
•
Plaque control programs, oral hygiene instruction, and dietary instructions;
•
Services to change vertical dimension and/or restore or maintain the occlusion. These
can include, but are not limited to, equilibration, periodontal splinting, full mouth
rehabilitation, and restoration for misalignment of teeth;
•
Gold foil restorations;
•
Treatment or services for injuries from the maintenance or use of a motor vehicle if such
treatment or service is paid or payable under a plan or policy of motor vehicle insurance,
including a certified self-insurance plan;
•
Treatment of services for injuries resulting from war or act of war, whether declared or
undeclared, or from police or military service for any country or organization;
•
Hospital costs or any additional fees that the dentist or hospital charges for treatment at
the hospital (inpatient or outpatient);
•
Charges by the provider for completing dental forms;
•
Adjustment of a denture or bridgework which is made within 6 months after installation
by the same Dentist who installed it;
•
Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels,
dental floss and teeth whiteners;
•
Cone Beam Imaging and Cone Beam MRI procedures;
•
Sealants for teeth other than permanent molars;
•
Precision attachments, personalization, precious metal bases and other specialized
techniques;
•
Replacement of dentures that have been lost, stolen or misplaced;
•
Orthodontic services provided to a dependent of an enrolled member who has not met
the 24 month waiting period requirement.
•
Orthodontic care for dependent children age 19 and over;
•
Repair of damaged orthodontic appliances;
•
Replacement of lost or missing appliances;
•
Fabrication of athletic mouth guard;
•
Internal and external bleaching;
•
Nitrous oxide;
•
Oral sedation;
•
Topical medicament center
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•
Orthodontic care for a member or spouse
•
Bone grafts in connection with extractions, apicoetomies or non-covered/non eligible
implants.
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