Surgical Periodontal Services Sample Clauses

Surgical Periodontal Services. Surgical periodontal service is the surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • Gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits are limited to one quadrant every 24 months. • Clinical crown lengthening. • Osseous surgery, including flap entry and closure – Benefits are limited to one per quadrant every 24 months. In addition, osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service, by the same Dentist, and in the same area of the mouth, will be processed as crown lengthening in the absence of periodontal disease. • Osseous grafts – Benefits are limited to one per site every 24 months. Benefits are not available for bone grafts in conjunction with extractions, apicoectomy or any non-covered service or non-covered implants. • Soft tissue grafts/allografts (including donor site). • Distal or proximal wedge procedure. Surgical periodontal services performed in conjunction with the placement of crowns, inlays, onlays, crown buildups, posts and cores, or basic restorations are considered part of the restoration. Benefits will not be provided for guided tissue regeneration, or for biologic materials to aid in tissue regeneration. Major Restorative Services Restorative services restore tooth structures lost as a result of dental decay or fracture and include: • Single crown restorations. • Inlay/onlay restorations. • Labial veneer restorations. Benefits will not be provided for the replacement of a lost, missing or stolen appliance and those for replacement of appliances that have been damaged due to abuse, misuse, or neglect. Benefits will not be provided to alter, restore, or correct vertical dimension of occlusion. Such procedures may include, but are not limited to equilibration dentures, crowns, inlays, onlays, bridgework, or dimension or to restore occlusion or to correct attrition, abrasion, erosion, or abfractions. Benefits will not be provided for the restoration of occlusion or incisal edges due to bruxism or harmful habits. Benefits for major restorations are limited to one per tooth every 60 months whether placement was provided under this contract or under any prior dental coverage, even if the original crown was stainless steel. Prosthodontic Services Prosthodontics involve procedures necessary for providing artificial replacements for missing natural teeth and includes: • Co...
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Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • Periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • Scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • Periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • Therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • Apexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • Endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • Pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • Endodontic therapy if you discontinue endodontic treatment. Oral Surgery Services Oral surgery means t...
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Surgical Periodontal Services. Non‐surgical periodontal service is the non‐surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • Periodontal scaling and root planing—Benefits are limited to one per quad­ rant every 24 months. • Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once every 12 months. • Periodontal maintenance procedures—Benefits are limited to two every 12 months in combination with routine oral prophylaxis and must be performed following active periodontal treatment. Benefits will not be provided for chemical treatments, localized delivery of chemotherapeutic agents without history of active periodontal therapy, or when performed on the same date (or in close proximity) as active periodontal therapy. Adjunctive Services Adjunctive general services include: • Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • Deep sedation/general anesthesia and intravenous sedation/non‐intravenous conscious sedation—By report only and when determined to be medically necessary for documented persons with a disability or for a justifiable medic­ al or dental condition. A person's apprehension does not constitute medical necessity. IL‐G‐H‐OF‐2016 82 • Nitrous Oxide analgesia will be covered. • Therapeutic parenteral drug injections will be covered. Benefits will not be provided for local anesthesia or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. • Root canal therapy, including treatment plan, clinical procedures, working and post‐operative radiographs and follow‐up care. • Apexification/recalcification procedures and apicoectomy/periradicular ser­ vices including Surgery, retograde filling, root amputations and hemisection. Pulpal debridement is considered part of endodontic therapy when performed by the same Provider and not associated with a definitive emergency visit. Benefits will not be provided for the following “Endondontic Services": • Endodontic retreatments provided within 12 months of the initial endodont­ ic therapy by the same Dentist. • Pulp vitality tests, endodontic endosseous implants, intentional reimplanta­ tions, canal preparation, fitting of performed dowel and post, or post removal. • Endodontic th...
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Related to Surgical Periodontal Services

  • 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.

  • Hospital Services The Hospital will:

  • Surgical Services All necessary procedures for extractions and other surgical procedures normally performed by a dentist.

  • Radiation Therapy/Chemotherapy Services This plan covers chemotherapy and radiation services. Respiratory Therapy This plan covers respiratory therapy services. When respiratory services are provided in your home, as part of a home care program, durable medical equipment, supplies, and oxygen are covered as a durable medical equipment service.

  • 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.

  • 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.

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • Prosthodontics We Cover prosthodontic services as follows: • Removable complete or partial dentures, for Members 15 years of age and above, including six (6) months follow-up care; • Additional services including insertion of identification slips, repairs, relines and rebases and treatment of cleft palate; and • Interim prosthesis for Members five (5) to 15 years of age. We do not Cover implants or implant related services. Fixed bridges are not Covered unless they are required: • For replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full complement of natural, functional and/or restored teeth; • For cleft palate stabilization; or • Due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis, as demonstrated by medical documentation.

  • Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. Durable Medical Equipment (DME) DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Preauthorization may be required for certain DME and replacement or repairs of DME. Medical Supplies Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. Diabetic Equipment and Supplies This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic Devices Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral Formulas or Food (Enteral Nutrition) Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.

  • Supplemental Services For requests for supplemental services relating to Epicor 9 and MFG Pro by Service Receiver not mentioned in this Schedule or not included within the costs documented in this agreement, Service Receiver will provide a discreet project request and submit such request to Service Provider using the formalized Change Request attached as Annex A for consideration by Service Provider. Where notice is required a number of business days prior to some required action by Service Provider, notice must be received by 12 noon Eastern Time to be counted as received during such business day. Service Provider shall, within a commercially reasonable period, provide a price quote to be commercially reasonable based on the current cost of the Services to Service Receiver taking into account, such items as the specific time the request was made, service delivery volumes, exit planning activities, and other activities Service Provider is currently engaged in at the time of the request, but not later than 30 days after the request was made. If Service Provider, in its sole discretion determines (i) such request would increase the ongoing operating costs for Service Provider (as a service recipient) or any other service receiver or (ii) that it is not capable of making such changes with its current staff during the time period requested without interrupting the Services provided to itself or any other service receiver. Service Provider need not provide a price quote or perform the services. Where a price quote is provided, Service Provider shall provide the service requested upon acceptance of the price.

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