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SCHEDULE B
EXCLUSIONS OF BENEFITS |
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- Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments;
- Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth;
- Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges);
- Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ);
- Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures;
- An initial treatment plan that involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered benefits. This exclusion does not eliminate the benefit for other covered services;
- Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment;
- Extraction/removal of an erupted, partially erupted or impacted tooth:
- Solely for orthodontic purposes;
- When the tooth exhibits no signs or symptoms of infection, cystic degeneration, fracture, caries and/or having caused damage to an adjacent tooth; or
- When the extraction or removal would be inconsistent with generally accepted professional standards;
- Consultations for non-covered benefits;
- Replacement of restorations, crowns, bridges, dentures or prosthetic teeth to enhance cosmetics and/or better match bleached teeth;
- Dental services received from any dental facility other than the assigned Contract Dentist including the services of an out-of-network dental specialist, unless expressly authorized by Delta or as cited under Emergency Services;
- Any procedure that in the professional opinion of the Contract Dentist:
- has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or
- is inconsistent with generally accepted standards for dentistry;
- All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility;
- Congenital malformations;
- Dispensing of drugs not normally utilized in the delivery of dental services;
- Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress;
- Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage;
- Dental conditions arising out of and due to Enrollee's employment for which Worker's Compensation is paid. Services that are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision;
- Treatment required by reason of war declared or undeclared;
- Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services;
- Specialist Services received from an orthodontist or pediatric dentist;
- Accidental injury. Accidental injury is defined as damage to the hard and soft tissue of the oral cavity resulting from forces external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function will be covered at the normal schedule of Benefits.
- Treatment of retained primary teeth.
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