Dental

What Is Not Covered

We will not pay Dental Insurance benefits for charges incurred for:

1. services which are not Dentally Necessary, or those which do not meet generally accepted standards of care for treating the particular dental condition;
2. services for which You would not be required to pay in the absence of Dental Insurance;
3. services or supplies received by You or Your Dependent before the Dental insurance starts for that person;
4. services which are neither performed nor prescribed by a Dentist, except for those services of a licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for;
   • scaling and polishing of teeth; or
   • flouride treatments
5. services which are primarily cosmetic, (For residents of Texas, see notice page section);
6. services or appliances which restore or alter occlusion or vertical dimension;
7. restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;
8. restorations or appliances used for the purpose of periodontal splinting;
9. counseling or instruction about oral hygiene, plaque control, nutrition and tabacco;
10. personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;
11. initial installation of a Denture or implant to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congentially missing teeth;
12. decoration or inscription of any tooth, device, appliance, crown or other dental work;
13. missed appointments;
14. services:
    • covered under any workers’ compensation or occupational disease law;
    • covered under any employer liability law;
    • for which the Employer of the person receiving such services is required to pay; or
    • received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital;
15. services covered under other coverage provided by the Policyholder;
16. biopsies of hard or soft oral tissue;
17. temporary or provisional restorations;
18. temporary or provisional appliances;
19. prescription drugs;
20. services for which the submitted documentation indicates a poor prognosis;
21. the following, when charged by the Dentist on a separate basis:
    • claim for completion;
    • infection control, such as gloves, masks, and sterilization of supplies, or
    • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide;
22. dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food;
23. caries susceptibility tests;
24. labial veneers;
25. modification of removable prosthodontic and other removable prosthetic services;
26. appliances or treatment for bruxism (grinding teeth);
27. adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
28. duplicate prosthetic devices or appliances;
29. replacement of a lost or stolen appliance, Cast Restoration or Denture;
30. replacement of an orthodontic device;
31. diagnosis and treatment of temporomandibular joint disorders and cone beam imaging associated with the treatment of temporomandibular joint disorders;
32. intra and extraoral photographic images.