Pedicle soft tissue graft - unlimited. Mesial/Distal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) - unlimited. Free soft tissue graft (including recipient and donor surgical sites) - unlimited. Autogenous connective tissue graft procedure (including donor and recipient surgical site surgery) - unlimited. Non‐autogenous connective tissue graft (including recipient site and donor material) - unlimited. Removal of non-resorbable barrier - unlimited. Removal of a non-resorbable barrier is considered inclusive to guided tissue regenerative services, unless performed by a Dentist other than the Dentist who installed it. Periodontal scaling and root planing - full mouth - unlimited. Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation. Limited to 2 per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, and scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit. Full Mouth Debridement - limited to one per lifetime. Adjustments to complete and partial dentures within 6 months of its installation is part of the allowance for adjustments and is not a separate Covered Dental Service. Repairs to complete and partial dentures within 6 months of its installation is part of the allowance for repairs and is not a separate Covered Dental Service. Rebasing dentures - limited to rebasing done more than 6 months after the initial insertion, and then not more than one time in any 36 month period. Relining dentures - limited to relining done more than 6 months after the initial insertion, and then not more than one time in any 36 month period. Soft Liner - Complete or Partial Removable Dentures - limited to services done more than 6 months after the initial insertion, and then not more than one time in any 36 month period. Tissue conditioning - maxillary or mandibular. Re-cement or re-bond crown, inlays, onlays, veneer or partial coverage restoration, indirectly fabricated or prefabricated post and core. Limited to repairs performed more than 6 consecutive months after the initial insertion. Crown repair and fixed partial dental repair. Limited to repairs performed more than 6 consecutive months after the initial insertion.
Re-cement fixed partial denture/bridge - limited to repairs done more than 6 months after the initial insertion. Routine extractions. Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. Removal of impacted tooth, soft tissue, partially bony, completely bony. Removal of residual tooth roots - 1 per tooth per lifetime. Coronectomy - 1 per lifetime. Biopsy of oral tissue. Brush biopsy. Alveoloplasty. Vestibuloplasty. Excision of benign cysts/lesions. Removal of exostosis (maxilla or mandible). Removal of torus services. Incision and drainage. Frenectomy/Frenuloplasty. Excision of hyperplastic tissue - per arch or pericoronal gingiva. Local anesthetic, analgesic and routine postoperative care for dental procedures are not separately reimbursed but are considered as part of the submitted fee for the global procedure. General anesthesia - Paid as a separate benefit only when Medically Necessary and/or Dentally Necessary, in accordance with Our clinical guidelines, and only when administered in conjunction with procedures which are covered under this plan. I. V. Sedation - Paid as a separate benefit only when Medically Necessary and/or Dentally Necessary, in accordance with Our clinical guidelines, and only when administered in conjunction with procedures which are covered under this plan. Consultation – diagnostic service provided by Dentist or physician other than the requesting Dentist or physician. Nitrous oxide.
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