The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless it is determined necessary for the prevention, diagnosis, care, or treatment of a covered condition. All out-of-network services listed in Section 5 are subject to the usual and customary maximum allowable fee charges as defined by Delta Dental's Federal Employees Dental Program. The member is responsible for all remaining charges that exceed the allowable maximum. Additionally, any dental service or treatment not listed in Section 5 as a covered service is not eligible for benefits.
We do not cover the following:
• Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of their license and applicable state law;
• Services and treatment which are experimental or investigational;
• Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation;
• Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group;
• Services and treatment performed prior to your effective date of coverage;
• Services and treatment incurred after the termination date of your coverage unless otherwise indicated;
• Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice.
• Services and treatment resulting from your failure to comply with professionally prescribed treatment;
• Telephone consultations;
• Any charges for failure to keep a scheduled appointment;
• Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
• Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMJD);
• Services or treatment provided as a result of intentionally self-inflicted injury or illness;
• Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection;
• Office infection control charges;
• Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
• State or territorial taxes on dental services performed;
• Those services submitted by a dentist, which are the same services performed on the same date for the same member by another dentist;
• Those services provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
• Those services for which the member would have no obligation to pay in the absence of this or any similar coverage;
• Those services which are for specialized procedures and techniques;
• Those services performed by a dentist who is compensated by a facility for similar covered services performed for members;
• Duplicate, provisional and temporary devices, appliances, and services;
• Plaque control programs, oral hygiene instruction, and dietary instructions;
• Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth;
• Gold foil restorations;
• Charges for sterilizing instruments;
• Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan;
• Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization;
• Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient);
• Charges by the provider for completing dental forms;
• Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it;
• Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners;
• Cone Beam Imaging and Cone Beam MRI procedures;
• Sealants for teeth other than permanent molars;
• Precision attachments, personalization, precious metal bases and other specialized techniques;
• Replacement of dentures that have been lost, stolen or misplaced;
• Repair of damaged orthodontic appliances;
• Replacement of lost or missing appliances;
• External bleaching;
• Nitrous oxide;
• Oral sedation;
• Topical medicament center;
• Bone grafts when done in connection with extractions, apicoectomies or non-covered/non eligible implants;
• When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by Delta Dental's Federal Employees Dental Program.
• When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), the Plan will pay for the service that represents the final treatment as determined by this plan.
• Any self-administered (mail order or do-it yourself) type of orthodontics are not covered.
• Laser Assisted New Attachment Procedure (LANAP), considered investigational in nature as determined by generally accepted dental practice standards.
General Policies
All covered services are subject to the following general policies:
- Services must be necessary to preserve functionality and maintenance of oral health to the teeth and supporting structures and must meet accepted standards of dental practice. Services determined to be unnecessary or which do not meet accepted standards of practice are not billable to the patient by a participating dentist unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment. Participating dentists shall document such notification in their records.
- The plan must provide an alternate benefit provision for benefits beyond the least expensive professionally accepted standard of care, whereby the patient pays the difference between the covered benefit and the more expensive treatment option.
- An appeal is not available when the services are determined to be unnecessary or do not meet accepted standards of dental practice unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment. This is because such services are not billable to the patient, and there would be no amount to dispute to consider an appeal.
- Procedures should be reported using the American Dental Association's (ADA) current dental procedure codes and terminology.
- Claims submitted for payment more than 12 months after the month in which a service is provided are not eligible for payment. A participating dentist may not bill the enrollee for services that are denied for this reason.
- Services, including evaluations, which are routinely performed in conjunction with or as part of another service, are considered integral. Participating dentists may not bill members for services denied if they are considered integral to another service.
- Charges for the completion of claim forms and submission of required information for determination of benefits are not payable to participating dentists by either the contractor or enrollee.
- Local anesthesia is considered integral to the procedure(s) for which it is provided.
- Payment for diagnostic services performed in conjunction with orthodontics may be applied to the member's annual maximum.
Class A Preventive Services
• Space maintainers for missing permanent teeth or primary anterior teeth (except primary cuspids)
• Repair of a damaged space maintainer;
Class B Minor Restorative Services
• Sedative restorations;
• Restorations performed after the placement of any type of crown or onlay on the same tooth and by the same dentist;
• Restorations placed due to abrasion, attrition, erosion, congenital or developmental malformations or to restore vertical dimension;
• Glass ionomer restorations;
Class B Periodontic Services
• Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal surgical procedures in the same area of the mouth;
Class B Prosthodontic Services
• For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however, the provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an Oral Surgeon, inserted the dentures.
Class B Oral Surgery Services
• Unsuccessful extractions;
• Removal of impacted third molars in patients under age 15 and over age 30 unless specific documentation is provided that substantiates the need for removal and it is approved by the contractor.
Class C Major Restorative Services
• Sedative restorations;
• Cast crowns with resin facings;
• Protective restoration;
• Composite resin inlays;
• Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to the effective date of coverage are not eligible for coverage.
Class C Endodontic Services
• Incomplete endodontic therapy due to the patient's discontinuation of treatment;
• A paste-type root canal filling incorporating formaldehyde or paraformaldehyde;
• Endodontic procedures in conjunction with overdentures;
• Incompletely filled root canals, other than for reason of an inoperable or fractured tooth;
Class C Prosthodontic Services
• Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to the effective date of coverage are not eligible for coverage.
Class D Orthodontic Services
• Myofunctional therapy is integral to orthodontic treatment and is not payable as a separate benefit;
• Orthodontic services for dependent children in the Standard Plan are only covered up to age 21 for TRICARE-eligible individuals (or 23 if they’re full-time college students) or 22 for civilian dependents;
• Orthodontic services for dependent children in the High Plan are only covered up to age 21 for TRICARE-eligible individuals (or 23 if they’re full-time college students) or 22 for civilian dependents. Orthodontic services for enrollees and spouses are only covered in the High Plan.
General Services
• Deep sedation/general anesthesia and intravenous conscious sedation without a report;
Adjunctive Services
• Adjunctive dental services, except as described in the General Services section of this plan brochure.