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SCHEDULE B
ORTHODONTIC EXCLUSIONS |
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- Pre-, mid- and post-treatment records that include cephalometric x-rays, tracings, photographs and study models.
- Lost, stolen or broken orthodontic appliances.
- Surgical procedures incidental to orthodontic treatment.
- Myofunctional therapy.
- Surgical procedures which are medical in nature and are related to cleft palate, micrognathia, or macrognathia.
- Treatment related to temporomandibular joint disturbances which is medical in nature.
- Supplemental appliances not routinely used in comprehensive orthodontics, including, but not limited to, palatal expander, habit control appliance, pendulum, quad helix, or herbst.
- Restorative work caused by orthodontic treatment.
- Phase I orthodontics, as well as activator appliances and minor treatment for tooth guidance and/or arch expansion. Phase I orthodontics is defined as early treatment including interceptive orthodontia prior to the development of lated mixed dentition.
- Extractions solely for the purpose of orthodontics.
- Treatment in progress at inception of eligibility.
- Patient initiated transfer after bands have been placed.
- Composite or ceramic brackets, lingual adaptation of orthodontic bands, and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.
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