GENERAL EXCLUSIONS FROM BENEFITS FOR DENTAL SERVICES
As a guide to members in their utilization of the Dental Benefit Plan, the following list specifies but does not limit the particular and general exclusions from the plan.
Payment will not be made for any expenses incurred:
- For any services, supplies, or treatment not prescribed by a legally qualified dentist or physician;
- For services rendered prior to the patient becoming eligible for benefits;
- For any dental or surgical procedure performed solely or substantially for cosmetic reasons;
- For procedures, restorations, or appliances performed or fabricated solely for cosmetic purposes or to increase vertical dimension, or to restore occlusion;
- For replacement of an existing crown, inlay, onlay, fixed bridge, or complete or partial removable denture until five years have elapsed from the date the service was originally completed and only if the crown, inlay, onlay, fixed bridge, or complete or partial removable denture being replaced is unsatisfactory and cannot be made satisfactory;
- For multiple abutting of teeth for prosthetic purposes when the additional teeth are free of decay and functionally sound, or for prosthetic appliances, fixed or removable, placed for the purpose of periodontal splinting;
- For charges for temporary crowns (unless tooth is fractured, and only on anterior teeth), or for temporary dental services which will be considered an integral part of the overall dental service rather than a separate service;
- For dental service performed by a dentist in which the Fund experiences an instance of unsatisfactory documentation or recording of services that is deemed detrimental to the Fund or the patient.
- All periodontal treatment must be reviewed and approved for benefits prior to treatment. The most inclusive periodontal service includes all related services performed on the same date in the same area and payment will be made for the all-inclusive service only. For osseous surgery (ADA code 4260) and gingivectomy (ADA code 4210) performed on the same date, payment will be made for the all-inclusive osseous surgery.
- For any benefit that is claimed after a period that exceeds one year from the calendar year in which dental services were rendered,
- For replacement of a lost, stolen or missing appliance or prosthetic device or the fabrication of a spare appliance or device;
- For dental supplies or services rendered for injuries or conditions compensable under Worker’s Compensation, Employer’s Liability laws, or “no fault” automobile insurance laws; dental services provided by a Federal or State or Provincial government agency, i.e., Veteran’s Administration Hospital, or provided without cost to the covered individual by any municipality, county, or political subdivision or community agency, except to the extent that such payments are insufficient to pay for the applicable eligible dental benefits contained in this plan;
- For dental supplies or services furnished by or for the United States Government or any local governmental agency or where reimbursement is made elsewhere;
- For services where a charge is not incurred or payment is not required;
- For dental services or supplies not listed or not consistent with the Schedule of Dental Benefits unless the Fund reviews the services and accepts the expenses as Covered Dental Expenses. The Covered Dental Expense for such services will be determined by the Fund and will be consistent with those listed in the Schedule;
- For treatment of disturbances of the temporomandibular joint, or myofacial pain;
- For treatment that does not meet currently accepted standards of dental procedures, or treatments that are experimental in nature;
- For orthodontic services provided when no severe malocclusion and/or functional problem exist;
- For analgesics (such as nitrous oxide) or other euphoric or prescription drugs; local anesthesia, or drugs that desensitize teeth;
- For any charges for broken appointments or completion of claim forms;
- For any charges for hospitalization, including hospital visits, laboratory tests and/or laboratory examinations; all other services and treatments not specifically listed as included in the Benefit Fund’s dental plan.
NOTE: Further information is available upon request. If you have any questions regarding the coverage, benefits or exclusions, please contact the Fund Office at (631) 319-4099.