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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.
- Repair or replacement of a sealant on any tooth within three years of its application.
- All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.
- Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers and crowns and fixed partial dentures (bridges).
- Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.
- 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, full or partial dentures for which an impression has been taken.
- Prescription drugs.
- Any procedure that in the professional opinion of the Contract Dentist or the dental consultant:
- 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.
- Dental services received from any dental facility other than the assigned Contract Dentist, or a preauthorized dental specialist (oral surgeon, endodontist, periodontist, pediatric dentist or Contract Orthodontist), except for Emergency Services as described in the Evidence of Coverage.
- Consultations for non-covered benefits.
- Implant supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant.
- Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.
- Services solely for cosmetic purposes, with the exception of procedure D9972, External bleaching, per arch, or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.
- Procedures, appliances or restorations if the purpose is to change vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or to diagnose or treat abnormal conditions 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.
- Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions.
- Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.
- Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.
- Accidental injury. Accidental injury is defined as damage to the hard and soft tissues 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.
- Pre-, mid- and post-treatment records which include cephalometric x-rays, tracings, photographs and study models.
- Changes in treatment necessitated by accident of any kind.
- Myofunctional and parafunctional appliances and/or therapies.
- 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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