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Your Covered Benefits |
Definition of Services |
Limitations |
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I. Preventive Services
Covered services include
office visits for oral prophylaxis,
topical fluoride application, oral
hygiene instruction sealants and space
maintainers.
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Oral prophylaxis to remove coronal plaque, calculus
and stains and includes scaling and polishing procedures.
Topical fluoride application includes application fluoride gel or
liquid to a tooth. Sealants are application to
pits and fissures of permanent teeth. Space
maintainers are covered for necessary maintenance of a posterior space
for a permanent successor to a prematurely lost deciduous tooth. |
Limited
to once every 6 months. Limited to one
application in a six month period. Application of fluoride to a tooth
prior to restoration is not covered.
Limited to one application per 1st and 2nd molar
every three years to age 16.
Space maintainers are limited to fixed appliances,
must be passive in nature and where the space must be maintained for
at least six months. |
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II. Oral Examinations
Covered services include office visits for a
comprehensive visual diagnostic examination of the oral cavity, teeth
and support structures.
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A comprehensive oral exam includes:
 | history health recording |
| caries detection |
| pulp testing when indicated |
| radiographic studies |
| written treatment plan |
A limited oral examination for a specific problem is
also covered when palliative treatment is provided on an episodic basis
to relieve pain and suffering. |
Following the initial examination, coverage is limited to a periodic
exam once every six months. |
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III. Analgesia Covered services include the
administration of a drug or agent to
temporarily arrest the feeling of pain
in a conscious individual.
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Limited to enrollees who have a
severe physical or mental
disability or is difficult to manage. Service is limited to three
times per twelve month
period.
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IV. Injectable Medications
Covered services include the
injection of medicine by a dentist in the
treatment of an illness or disease.
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V. Sedation/General Anesthesia Covered services include the
intravenous and non-intravenous
administration of drugs or agents.
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Non-intravenous sedation
is limited to three times per 366 day period. |
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VI. Oral Surgery Services
Covered services include
extractions, biopsies, surgical and
adjunctive treatment of diseases, injuries, deformities and defects of
the oral and maxillofacial areas.
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Covered services include local
anesthesia and routine post-operative care. Biopsies are the removal
of tissue, hard or soft, from the recipient for microscopic
examination for the purpose of diagnosis, prognosis and treatment
planning. |
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VII. Palliative Treatment
Covered services are those
services necessary to relieve pain and
discomfort on an emergency basis.
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Limited to those instances where
circumstances contraindicate more definitive treatment or
services.
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VIII. Endodontic Services
Covered services include
office visits and treatment for pulp capping, therapeutic pulpotomies,
root canal therapy, apexification and
apicoectomies.
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Root canal therapy on primary teeth with
permanent teeth present must include the placement of a resorable
filling. Root canal therapy on permanent teeth or primary teeth
without permanent teeth present includes the placement of non-resorbable
filling. Apexification is the clinical
treatment involving the necrosis of the pulp of incompletely formed
decidous and permanent teeth subsequent to trauma or dental caries.
Apicoectomy is defined as surgery involving the
amputation of the apex of the tooth. |
Root canal therapy is
limited to those situations where the teeth have a restorable crown;
the prognosis of the tooth is not questionable; and the exfoliation of
the deciduous tooth is not anticipated within eighteen months.
Apicoectomy is covered
only when one of the
following conditions exist:
| overfilled canal or
canal cannot be filled due to excess root
curvature |
| fractured root tip
is not reachable |
| broken instrument in
canal |
| perforation of the
root in the apical one-third of canal |
| root canal
filling material lying free in
periapical tissues and acting as
irritants |
| root canal therapy
is a failure |
| periapical
pathology not resolved by
root canal therapy. |
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| IX.
Periodontal Services
Covered services include gingivectomy, gingival
curettage, gingival flap procedure, scaling and root planing. Services
also include any necessary postoperative care.
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Gingival
curettage is the surgical procedure of scraping and cleaning the soft
tissue wall of the periodontal pocket. This service is performed
under local anesthesia in conjunction with root instrumentation. Ginigival flap procedure is the surgical debridement
of the root surface and the removal of granulation tissue following
resection of the soft tissue flap including root planing.
Periodontal scaling and root planing involve
instrumentation of the crown and root surfaces of the teeth to remove
plaque and calculus from these surfaces.
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Periodontal scaling and root planing is done in the presence of
periodontal pocket depths of 4 mm or greater. |
| X.
Restorative Services
Covered services include those services necessary to
eliminate carious or post traumatic lesions from teeth and to restore
the anatomic shape, function and esthetics of teeth.
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Services
include the following:
| amalgam restorations |
| resin restorations, including composite and
glass-ionomers |
| pre-fabricated stainless steel crowns for both
deciduous and permanent teeth |
| specified crown types. |
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Surgical periodontal services are done in the
presence of periodontal pocket depths of 5 mm or greater.
Restorations are not covered on primary teeth if loss
is expected within six months. Sealants applied in conjunction with
preventive resin are not covered. Crowns provided solely for aesthetic
reasons are not covered. Fixed bridges or partial dentures are not
covered. |
| XI.
Consultation Services
Covered services include examination of the enrollee
evaluation of condition, recommendation for treatment documentation in
enrollee's dental records and a written report to the requesting
dentist or physician.
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Consultation must be provided by an accredited dental specialist whose
opinion or advice regarding the evaluation or management of the
specific problem is requested by another dentist. |
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| XII.
Orthodontic Services
Covered services include fixed appliance therapy and
monthly maintenance visits.
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Orthodontic services must be provided by specially trained
orthodontics and pediatric dentists. |
Services
are limited to those circumstances where the enrollee's condition
creates a disability and is an impairment to their physical
development. Monthly maintenance visits are limited to a maximum of 24
months.
Extensions are granted only in the most severe cases.
Any lapsation in coverage will not becovered.
Services will not be covered if services are for:
| limited or interceptive treatment |
| primarily cosmetic purposes, including crowding
of teeth |
| split phase treatment, with the exception for
cleft palate cases. |
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| XIII.
Hospitalization for Dental Treatment
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Enrollee's health must be so jeopardized that the procedures cannot be
solely performed in the office; and/or the enrollee is so
uncontrollable due to emotional instability that sedation has been ineffective. |
| XIV.
Radiographic Examinations
Covered services include intraoral, extraoral and
panoramic radiographs necessary to make a diagnosis of dental disease
or trauma.
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Limited
to radiographs of intraoral periapical, bitewing, occlusal and
panoramic radiographs necessary to make a diagnosis and to develop a
treatment plan. Complete set of intraoral radiographs is limited to
once in a three year period. Bitewings are limited to once in a six
month period. A panoramic radiograph is limited to once per year. |
| XV.
Removable Prosthodontics
Covered services include the fabrication, repairing,
relining, and adjusting of an immediate or non-immediate appliance for
the replacement of extracted teeth under the direction of a dentist.
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Complete
dentures may be provided once for upper, a lower or a complete set for
the lifetime of the enrollee. Exceptions may be granted if the
dentures are no longer functional because of the enrollee's physical
condition or the condition of the denture. |
