Common use of Surgical Periodontal Services Clause in Contracts

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: • Complete and removable partial dentures – Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustments, relines or rebases during the six-month period following installation. Benefits for replacements are limited to once in any 60-month period, whether placement was provided under this contract or under any prior dental coverage. Benefits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture reline/rebase procedures – Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placement. • Fixed bridgework – Benefits will be provided for the initial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coverage. NOTE: Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery.

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 gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits are limited to one quadrant every 24 months. • Clinical clinical crown lengthening. • Osseous 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 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 soft tissue grafts/allografts (including donor site). • Distal 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 single crown restorations. • Inlayinlay/onlay restorations. • Labial 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: • Complete complete and removable partial dentures – Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustments, relines or rebases during the six-month period following installation. Benefits for replacements are limited to once in any 60-month period, whether placement was provided under this contract or under any prior dental coverage. Benefits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture denture reline/rebase procedures – Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placement. • Fixed fixed bridgework – Benefits will be provided for the initial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coverage. NOTE: Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery.

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: • Complete and removable partial dentures – Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustments, relines or rebases during the six-month period following installation. Benefits for replacements are limited to once in any 60-month period, whether placement was provided under this contract or under any prior dental coverage. Benefits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture reline/rebase procedures – Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placement. • Fixed bridgework – Benefits will be provided for the initial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coverage. NOTE: Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery. NOTE: An implant is a covered procedure of the Plan only if determined to be a dental necessity. Claim review for implant services are conducted by licensed dentists who review the clinical documentation submitted by your treating dentist. If the dental consultants determine an arch can be restored with a standard prosthesis or restoration, no benefit will be allowed for the individual implant or implant procedure. Only the second phase of treatment (the prosthodontic phase-placement of the implant crown, bridge, or partial denture) may be subject to the alternate benefit provision of the Plan. • Implant retained crowns, bridges, and dentures are subject to the alternate benefit provision of the Plan. • Endosteal, eposteal, and transosteal implants – one every 60 months only if determined to be a dental necessity. Benefits will not be provided for the following Prosthodontic Services: • Treatment to replace teeth which were missing prior to the Effective Date. • Congenitally missing teeth. • Splinting of teeth, including double retainers for removable partial dentures and fixed bridgework. Miscellaneous Restorative and Prosthodontic Services Other restorative and prosthodontics services include: • Prefabricated crowns – Benefits for stainless steel and resin-based crowns are limited to one per tooth every 60 months. These crowns are not intended to be used as temporary crowns. • Recementation of inlays/onlays, crowns, bridges, and post and core –Any recementation provided within six months of an initial placement by the same Dentist is considered part of the initial placement. • Core build up, post and core, and prefabricated post and core are limited to 1 per tooth every 60 months. • Crown and bridge repair services. • Pulp cap – direct and indirect. • Prosthodontic service adjustments.  Repairs of inlays, onlays, veneers, crowns, fixed or removable dentures, including replacement or addition of missing or broken teeth or clasp.

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: • Complete and removable partial dentures – Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustments, relines or rebases during the six-month period following installation. Benefits for replacements are limited to once in any 60-month period, whether placement was provided under this contract or under any prior dental coverage. Benefits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture reline/rebase procedures – Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placement. • Fixed bridgework – Benefits will be provided for the initial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coverage. NOTE: Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery. NOTE: An implant is a covered procedure of the Plan only if determined to be a dental necessity. Claim review for implant services are conducted by licensed dentists who review the clinical documentation submitted by your treating dentist. If the dental consultants determine an arch can be restored with a standard prosthesis or restoration, no benefit will be allowed for the individual implant or implant procedure. Only the second phase of treatment (the prosthodontic phase-placement of the implant crown, bridge, or partial denture) may be subject to the alternate benefit provision of the Plan. • Implant retained crowns, bridges, and dentures are subject to the alternate benefit provision of the Plan. • Endosteal, eposteal, and transosteal implants – one every 60 months only if determined to be a dental necessity. Benefits will not be provided for the following Prosthodontic Services: • Treatment to replace teeth which were missing prior to the Effective Date. • Congenitally missing teeth. • Splinting of teeth, including double retainers for removable partial dentures and fixed bridgework. Miscellaneous Restorative and Prosthodontic Services Other restorative and prosthodontics services include: • Prefabricated crowns – Benefits for stainless steel and resin-based crowns are limited to one per tooth every 60 months. These crowns are not intended to be used as temporary crowns. • Recementation of inlays/onlays, crowns, bridges, and post and core –Any recementation provided within six months of an initial placement by the same Dentist is considered part of the initial placement. • Core build up, post and core, and prefabricated post and core are limited to 1 per tooth every 60 months. • Crown and bridge repair services. • Pulp cap – direct and indirect. • Prosthodontic service adjustments. • Repairs of inlays, onlays, veneers, crowns, fixed or removable dentures, including replacement or addition of missing or broken teeth or clasp.

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 includesinclude: • Gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits planing)—Benefits are limited to one per quadrant every 24 months. • Clinical crown lengthening. • Osseous surgery, including flap entry and closure – 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 – 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)site)—Benefits are limited to one per site every 24 months. • Distal or proximal wedge procedure. • Anatomical crown exposures—Benefits are limited to one per quadrant every 24 months. 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 ma­ terials to aid in tissue regeneration. Major Restorative Services Restorative services restore tooth structures lost as a result of dental decay or fracture frac­ ture and include: • Single crown restorations. • InlayGold foil and inlay/onlay restorations. • Labial veneer restorations. IL‐G‐H‐OF‐2016 84 Benefits will not be provided for the replacement of a lostlost or defective crown. However, 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 on 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 coveragemonths, even if the original crown was stainless steel. Crowns placed over implants will be covered. Prosthodontic Services Prosthodontics involve procedures necessary for providing artificial replacements replace­ ments for missing natural teeth and includes: • Complete (upper and lower dentures) and removable partial dentures – Benefits (upper and lower dentures)—Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustmentsadjust­ ments, relines or rebases during the six-month six‐month period following installation. Benefits for replacements are limited to once in any 60-month 60‐month period, whether placement was provided under this contract or under any prior dental coverage. Benefits Bene­ fits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture reline/rebase procedures – procedures—Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placementproced­ ure every 24 months. • Fixed bridgework – Benefits (fixed prosthetics)—Benefits will be provided for the initial ini­ tial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coveragemonths. NOTE: • Maxillofacial Prosthetics Prosthetics placed over implants will be covered. Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery. Benefits will not be provided for the following Prosthodontic Services: • Treatment to replace teeth which were missing prior to the Coverage Date, except those teeth missing due to congenital malformation. • Splinting of teeth, including double retainers for removable partial dentures and fixed bridgework. Miscellaneous Restorative and Prosthodontic Services Other restorative and prosthondontics services include: • Prefabricated crowns—Benefits for stainless steel and resin‐based crowns are limited to one per tooth every 60 months. These crowns are not intended to be used as temporary crowns. • Recementation of inlays/onlays, crowns, bridges, and post and core—Bene­ fits will be limited to two recementations every 12 months. However, any recementation provided within six months of an initial placement by the same Dentist is considered part of the initial placement. • Post and core, pin retention, and crown and bridge repair services. IL‐G‐H‐OF‐2016 85 • Pulp cap—direct and indirect. • Adjustments—Benefits will be limited to three times per appliance every 12 months. • Repairs of inlays, onlays, veneers, crowns, fixed or removable dentures, in­ cluding replacement or addition of missing or broken teeth or clasp (unless additions are completed on the same date as replacement partials/dentures) are limited to a lifetime maximum of once per tooth or clasp. Orthodontic Dental Services Orthodontic procedures and treatment include examination records, tooth guid­ ance and repositioning (straightening) of the teeth. Covered services include: • Diagnostic orthodontic records and radiographs. • Limited, interceptive and comprehensive orthodontic treatment. • Orthodontic retention.

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 includesinclude: • Gingivectomy or gingivoplasty and gingival flap procedures (including root planing) – Benefits planing)—Benefits are limited to one per quadrant every 24 months. • Clinical crown lengthening. • Osseous surgery, including flap entry and closure – 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 – 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)site)—Benefits are limited to one per site every 24 months. • Distal or proximal wedge procedure. • Anatomical crown exposures—Benefits are limited to one per quadrant every 24 months. 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 ma- terials to aid in tissue regeneration. Major Restorative Services Restorative services restore tooth structures lost as a result of dental decay or fracture frac- ture and include: • Single crown restorations. • InlayGold foil and inlay/onlay restorations. • Labial veneer restorations. Benefits will not be provided for the replacement of a lostlost or defective crown. However, 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 on 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 coveragemonths, even if the original crown was stainless steel. Crowns placed over implants will be covered. Prosthodontic Services Prosthodontics involve procedures necessary for providing artificial replacements replace- ments for missing natural teeth and includes: • Complete (upper and lower dentures) and removable partial dentures – Benefits (upper and lower dentures)—Benefits will be provided for the initial installation of removable complete, immediate or partial dentures, including any adjustmentsadjust- ments, relines or rebases during the six-month six‐month period following installation. Benefits for replacements are limited to once in any 60-month 60‐month period, whether placement was provided under this contract or under any prior dental coverage. Benefits Bene- fits will not be provided for replacement of complete or partial dentures due to theft, misplacement or loss. • Denture reline/rebase procedures – procedures—Benefits will be limited to one in a 36 month period after the initial 6 month period following initial placementproced- ure every 24 months. • Fixed bridgework – Benefits (fixed prosthetics)—Benefits will be provided for the initial ini- tial installation of a bridgework, including inlays/onlays and crowns. Benefits will be limited to once every 60 months whether placement was under this contract or under any prior dental coveragemonths. NOTE: • Maxillofacial Prosthetics Prosthetics placed over implants will be covered. Tissue conditioning is part of a denture or a reline/rebase, when performed on the same day as the delivery. Benefits will not be provided for the following Prosthodontic Services: • Treatment to replace teeth which were missing prior to the Coverage Date, except those teeth missing due to congenital malformation. • Splinting of teeth, including double retainers for removable partial dentures and fixed bridgework. Miscellaneous Restorative and Prosthodontic Services Other restorative and prosthondontics services include: • Prefabricated crowns—Benefits for stainless steel and resin‐based crowns are limited to one per tooth every 60 months. These crowns are not intended to be used as temporary crowns. • Recementation of inlays/onlays, crowns, bridges, and post and core—Bene- fits will be limited to two recementations every 12 months. However, any recementation provided within six months of an initial placement by the same Dentist is considered part of the initial placement. • Post and core, pin retention, and crown and bridge repair services. • Pulp cap—direct and indirect. • Adjustments—Benefits will be limited to three times per appliance every 12 months. • Repairs of inlays, onlays, veneers, crowns, fixed or removable dentures, in- cluding replacement or addition of missing or broken teeth or clasp (unless additions are completed on the same date as replacement partials/dentures) are limited to a lifetime maximum of once per tooth or clasp. Orthodontic Dental Services Orthodontic procedures and treatment include examination records, tooth guid- ance and repositioning (straightening) of the teeth. Covered services include: • Diagnostic orthodontic records and radiographs. • Limited, interceptive and comprehensive orthodontic treatment. • Orthodontic retention.