Common use of Services Not Medically Necessary Clause in Contracts

Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines.  Services Not Performed Within Indicated Time Limitations - Dental services performed that do not comply with the timeframes and limitations as set forth in this agreement and in our dental policies and related guidelines are NOT covered.  Anesthesia - General anesthesia and intravenous sedation are NOT covered unless rendered in conjunction with specific oral surgery procedures in accordance with Blue Cross Dental treatment guidelines. Please contact Customer Service for specific questions.  Cosmetic Services - This agreement does NOT cover cosmetic procedures. Cosmetic procedures are performed to refine or reshape dental structures that are not functionally impaired, to change or improve appearance or improve self-esteem, or for other psychological, psychiatric or emotional reasons.  Implants - This agreement does NOT cover dental implants, implant support prosthesis, or other implant related services, except for a single tooth implants which are covered as a prosthodontic service if placed as an alternative treatment to a conventional 3-unit bridge, replacing only one missing tooth when there are sound natural teeth on either side.  Experimental/Investigational Services - This agreement does NOT cover experimental or investigational procedures or services. Experimental or investigational procedures or services are not included in our dental policies and related guidelines. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective.  Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen.  New Dental Services - This agreement does NOT cover any new dental procedures or services that are not included in our dental policies and related guidelines.  Services Performed By Hospital Staff Employees - This agreement does NOT cover pediatric dental services rendered at a hospital by interns, residents, or staff dentists.  Specialty Oral Examinations - We will NOT cover oral examinations (limited in scope) when performed by a dentist who limits his or her practice to a specialty branch of dentistry. This includes, but is not limited to, oral examinations relating to periodontics, orthodontics, endodontics, oral surgery, and prosthodontics.  Temporomandibular Joint Syndrome (TMJ) - Services for or related to the treatment of TMJ are NOT covered. This agreement does NOT cover appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. See Section 4.18 for other Dental Services not covered under this agreement.

Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines.  Services Not Performed Within Indicated Time Limitations - Dental services performed that do not comply with the timeframes and limitations as set forth in this agreement and in our dental policies and related guidelines are NOT covered.  Anesthesia - General anesthesia and intravenous sedation are NOT covered unless rendered in conjunction with specific covered oral surgery procedures in accordance with Blue Cross Dental treatment guidelinessurgical procedures. Please contact Customer Service for specific questionsCovered dental care services excludes the services of an anesthesiologist.  Cosmetic Services - This agreement does NOT cover cosmetic procedures. Cosmetic procedures are performed to refine or reshape dental structures that are not functionally impaired, to change or improve appearance or improve self-esteem, or for other psychological, psychiatric or emotional reasons.  Implants - This agreement does NOT cover dental implants, implant support prosthesis, or other implant related services, except for a single tooth implants which are covered as a prosthodontic service if placed as an alternative treatment to a conventional 3-unit bridge, replacing only one missing tooth when there are with sound natural teeth on either side.  Experimental/Investigational investigational Services - This agreement does NOT cover experimental or investigational procedures or services. Experimental or investigational procedures or services are not included in our dental policies and related guidelines. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective.  Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen.  New Dental Services - This agreement does NOT cover any new dental procedures or services that are not included in our dental policies and related guidelines.  Services Performed By Hospital Staff Employees - This agreement does NOT cover pediatric dental services rendered at a hospital by interns, residents, or staff dentists.  Specialty Oral Examinations - We will NOT cover oral examinations (limited in scope) when performed by a dentist who limits his or her practice to a specialty branch of dentistry. This includes, but is not limited to, oral examinations relating to periodontics, orthodontics, endodontics, oral surgery, and prosthodontics.  Temporomandibular Joint Syndrome (TMJ) - Services for or related to the treatment of TMJ are NOT covered. This agreement does NOT cover appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. See Section 4.18 for other Dental Services not covered under this agreement.

Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines.  • Services Not Performed Within Indicated Time Limitations - Dental services performed that do not comply with the timeframes and limitations as set forth in this agreement and in our dental policies and related guidelines are NOT covered.  • Anesthesia - General anesthesia and intravenous sedation are NOT covered unless rendered in conjunction with specific oral surgery procedures in accordance with Blue Cross Dental treatment guidelines. Please contact Customer Service for specific questions.  • Cosmetic Services - This agreement does NOT cover cosmetic procedures. Cosmetic procedures are performed to refine or reshape dental structures that are not functionally impaired, to change or improve appearance or improve self-esteem, or for other psychological, psychiatric or emotional reasons.  • Implants - This agreement does NOT cover dental implants, implant support prosthesis, or other implant related services, except for a single tooth implants which are covered as a prosthodontic service if placed as an alternative treatment to a conventional 3-unit bridge, replacing only one missing tooth when there are sound natural teeth on either side.  • Experimental/Investigational Services - This agreement does NOT cover experimental or investigational procedures or services. Experimental or investigational procedures or services are not included in our dental policies and related guidelines. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective.  • Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen.  • New Dental Services - This agreement does NOT cover any new dental procedures or services that are not included in our dental policies and related guidelines.  • Services Performed By Hospital Staff Employees - This agreement does NOT cover pediatric dental services rendered at a hospital by interns, residents, or staff dentists.  • Specialty Oral Examinations - We will NOT cover oral examinations (limited in scope) when performed by a dentist who limits his or her practice to a specialty branch of dentistry. This includes, but is not limited to, oral examinations relating to periodontics, orthodontics, endodontics, oral surgery, and prosthodontics.  • Temporomandibular Joint Syndrome (TMJ) - Services for or related to the treatment of TMJ are NOT covered. This agreement does NOT cover appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. See Section 4.18 for other Dental Services not covered under this agreement.