Dentures. 1. Partial removable dentures, upper or lower, limited to one per 60 months. 2. Complete removable dentures, upper or lower, limited to one per 60 months. 3. Pre-operative radiographs required. 4. Pre-treatment estimate, as described in Section 15.3F, Estimate of Eligible Benefits, is recommended. 5. Tissue conditioning prior to denture impression only. 6. Repairs to denture as required including: repair resin denture base, repair cast framework, addition of tooth or clasp to existing partial denture, replacement of broken tooth, repairs or replacement of clasp, recement fixed partial denture. 7. Adjustment to maxillofacial prosthetic appliance, by report, limited to one per 6 months, per Member. 8. Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, limited to one per 6 months, per Member, per arch.
Appears in 2 contracts
Sources: Student Health Plan Individual Enrollment Agreement, Student Health Plan Individual Enrollment Agreement