Exclusions and Limitations

1. Anything not furnished by a dentist, except X-rays ordered by a dentist, and services by a licensed dental hygienist under the dentist's supervision; anything not necessary or not customarily provided for dental care.
2. Services (a) furnished by or for the US Government, or (b) furnished by or for any other government unless payment is legally required, or (c) to the extent provided under any governmental program or law under which the individual is, or could be, covered.
3. Any treatment started before the patient was covered.
4. The benefit for a cast restoration, crown, bridge, full or partial denture is limited to once every five years.
5. Services due to an accident related to employment or disease covered under Workers' Compensation or similar law.
6. Replacement of lost or stolen appliances; appliances or restorations for the purpose of splinting or to increase vertical dimension.
7. Any dental procedure performed for purely cosmetic reasons or for congenital malformations.
8. Gold restorations and crowns are covered only when teeth cannot be restored with a filling material.
9. Cast restorations and laboratory processed restorations including crowns, fixed bridges and dentures are not covered for a patient under the age of 16 years.
10. A fixed bridge and a removable partial denture on the same arch are not covered within a 5 year period.
11. Distal extension (cantilever) pontics are not covered.
12. Periodontal surgery is covered only following curettage or root planning and when need is documented by x-rays and periodontal charting.
13. For evaluation of specific sites, such as extraction of third molars, single film benefits allowance can be made.
14. Prophylaxis is not covered when performed on the same day as curettage or root planning.
15. Treatment for Temporomandibuar Joint Syndrome (TMJ).
16. Composite fillings are covered the same as amalgam fillings.
17. Sealants are covered only on permanent molars on patients under age 18.
18. Tooth structure replacement due to attrition or erosion.
19. Tissue graft surgery for periodontal disease except benefits are payable for free soft tissue graft procedures on a per site basis when submitted documentation demonstrates complete lack of attached gingival or progressive attached gingival recession of more than three millimeters.
20. Implants.
21. Emergency oral examination is covered when no other procedure is performed on the same day.
22. Only 5 intraoral x-rays, each additional film (procedure code 0230) are covered when performed on the same day.
23. Adult Prophylaxis is covered every 6 months, and with a letter of medical necessity, a cleaning is allowed every 3 months.
24. Fluoride treatment is covered for patients under age 18.
25. A pulp cap performed the same day as a restoration is not covered.
26. The allowance for endodontic therapy includes all appointments necessary to complete treatment and also includes intra-operative x-rays.
27. Benefits for curettage or root planning are payable once per quadrant in a 24 month period.
28. Denture adjustments are not covered for 6 months following denture placement or repair.
29. Benefits for oral surgery include local anesthesia and all post-operative care.
30. General anesthesia is only covered in conjunction with oral surgery.
31. Build ups are covered when insufficient tooth structure remains to retain a crown.
32. Posts are covered when insufficient coronal structure for crown retention is demonstrated by x-rays.
33. The benefits for a post and core includes the core or build up.
34. A fixed bridge is not covered where there is a large number of missing teeth in the same arch and/or moderate to advance bone loss is evident.
35. A crown or bridge is not covered when x-rays demonstrate moderate to advanced periodontal bone loss.
36. Benefits paid for surgical procedures include post-operative care.
37. Benefits are payable for a clinical crown lengthening only when Pretreatment x-rays demonstrate coronal destruction at or below the alveolar bone.