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Transcript
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.) -7- 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 - 11 - 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 - 13 - • • 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; - 14 - • 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 - 15 - • Orthodontic care for a member or spouse • Bone grafts in connection with extractions, apicoetomies or non-covered/non eligible implants. - 16 -