Dental Services Not Covered Sample Clauses

Dental Services Not Covered. Dental services performed that do not comply with the timeframes and limitations in our dental policies and related guidelines. • New dental procedures or services that are not included in our dental policies and related guidelines. • Dental services rendered at a hospital by interns, residents, or staff dentists. • Limited scope oral examinations when performed by a dentist who limits his or her practice to a specialty branch of dentistry. Examples include oral examinations for periodontics, orthodontics, endodontics, and oral surgery. • Orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen. • Services of an anesthesiologist. • General anesthesia and intravenous sedation, unless rendered in conjunction with covered oral surgical procedures. • Cosmetic procedures that are performed: o to refine or reshape dental structures that are not functionally impaired; o to change or improve appearance or improve self-esteem; or o for other psychological, psychiatric or emotional reasons. • Dental implants for members age nineteen (19) and older, except for the limited circumstance described in Section 3 for a single tooth implant. • Implant support prosthesis. • Injectable or prescription drugs. • Experimental or investigational procedures or services. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective. • Services completed prior to the effective date of this plan. • Occlusal guards to treat temporomandibular joint dysfunction (TMJ), sleep apnea, or snoring. • Occlusal guards when used as an athletic mouth guard or orthodontic retainer. • Services for or related to the treatment of TMJ. • Appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Travel expenses or other related expenses that may be incurred by a dentist providing services.
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Dental Services Not Covered. D0320 TMJ arthrogram D0321 Other TMJ films D0322 Tomographic survey D0360 Cone Beam CT D0362 Cone Beam multiple images 2 dim. D0363 Cone Beam multiple images 3 dim. D0416 Viral culture D0418 Analysis of saliva example chemical or biological analysis of saliva for diagnostic purposes. D0425 Caries test 0431 Adjunctive pre-diagnostic test D0475 Declassification procedure D0476 Special stains for microorganisms D0477 Special stains not for microorganisms 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 D7292 Surgical replacement screw retained D7293 Surgical replacement without the surgical flap D7880 TMJ Appliance D7899 TMJ Therapy D7951 Sinus Augmentation with bone or bone substitutes D7997 Appliance removal D7998 Intraoral placement of a fixation device D2410 Gold Foil 1 surface D2420 Gold Foil 2 surface D2430 Gold Foil 3 surface D2799 Provisional crown D2955 Post removal D2970 Temporary crown D2975 Coping D3460 Endodontic Implant D3470 Intentional reimplantation D3910 Surgical procedure for isolation of tooth D3950 Canal preparation D4230 Anatomical crown exposure 4 or more teeth D4231 Anatomical crown exposure 1-3 teeth D4320 Splinting intracoronal D4321 Splinting extracoronal D5810 Complete denture upper (interim) D5811 Complete denture lower (interim) D5820 Partial denture upper (interim) D5821 Partial denture lower (interim) D5862 Precision attachment D5867 Replacement Precision attachment D5986 Fluoride Gel Carrier D6057 Custom abutment D6253 Provisional Pontic D6254 Interim pontic D6795 Interim retainer crown D6920 Connector bar D6940 Stress breaker D6950 Precision Attachment D6975 Coping 'mental - Dental or Orthodontic care for dependent children age 19 and over - Dental or Orthodontic care for members and spouses - Repair to damaged orthodontic appliances - Replacement of lost or missing orthodontic appliances - Orthodontic services provided to a dependent of an enrolled member who has not met the 24-month continuous waiting period requirement
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Related to Dental Services Not Covered

  • Dental Services The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. Dialysis Services • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

  • Dental Services Plan The Corporation agrees to provide a Dental Plan for the benefit of Regular Full-Time Employees who have completed six (6) months of continuous service and Temporary Full-Time Employees who have completed twelve (12) months of continuous service which provides for the following services:

  • General Services (1) Services to be provided on an ongoing basis to the extent applicable to a particular Fund:

  • Special Services Should the Trust have occasion to request the Adviser to perform services not herein contemplated or to request the Adviser to arrange for the services of others, the Adviser will act for the Trust on behalf of the Fund upon request to the best of its ability, with compensation for the Adviser's services to be agreed upon with respect to each such occasion as it arises.

  • Hospital Services The Hospital will:

  • Incidental Services 13.1 The supplier may be required to provide any or all of the following services, including additional services (if any) specified in the SCC:

  • Medical Services Plan 10.1.1 Regular Full-Time and Temporary Full-Time Employees shall be entitled to be covered under the Medical Services Plan commencing the first day of the calendar month following the date of employment.

  • Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. Preauthorization may be required for certain surgical services. Reconstructive Surgery for a Functional Deformity or Impairment This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia. Preauthorization may be required for these services.

  • LIMITATIONS OF COVERED MEDICAL SERVICES In order to be covered, the Member’s Attending Physician must specifically prescribe such services and such services must be consequent to treatment of the cleft lip or cleft palate.

  • Anesthesia Services This plan covers general and local anesthesia services received from an anesthesiologist when the surgical procedure is a covered healthcare service. This plan covers office visits or office consultations with an anesthesiologist when provided prior to a scheduled covered surgical procedure.

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