and/or removal of an existing implant(s). Implant removal is covered only if the implant is not serviceable and cannot be repaired. Implant coverage may have a separate deductible amount, yearly maximum and/or lifetime maximum as shown in The Schedule.
• a combination of radiographic images (such as ten or more periapical radiographic images; or a panoramic radiographic image with bite-wing radiographic images) completed on the same date of service will not be covered when the allowance meets or exceeds the allowance for an intraoral complete series of radiographic images. Plan reimbursement will be based on an intraoral complete series; • Cone Beam CT; • localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth. Allowable only on teeth with both periodontal pocket depths of 5 mm or greater and a prior history of periodontal therapy. Not allowable when more than eight (8) of these procedures are reported on the same date of service; • tissue preparation such as gingivectomy/gingivoplasty or crown lengthening as a separate allowance on the same date as a restoration on the same tooth; • when covered by Your plan, any prosthesis over an implant is subject to the same exclusions, limitations, frequency limitations as standard traditional restorative, fixed and removable prosthetics; • Covered Dental Services to the extent that billed charges exceed the rate of reimbursement as described in The Schedule; • any replacement of a crown, bridge, partial denture, or complete denture which is or can be made usable according to commonly accepted dental standards; • crowns, inlays, cast restorations, or other laboratory prepared or CAD/CAM prepared restorations on teeth unless the tooth cannot be restored with an amalgam or resin-based composite restoration due to major decay or fracture; The benefits provided under this plan will be reduced so that the total payment will not be more than 100% of the charge made for the dental service if benefits are provided for that service under this plan and any expense plan or prepaid treatment program sponsored or made available by Your Employer.
HC-DEN346
06-21
General Limitations and Expenses Not Covered General Limitations For limitations on specific Covered Dental Services, please see the Covered Dental Services. • any treatment received outside of the United States is not covered unless the treatment is a Covered Dental Service under the plan. Any benefits for services received outside of the United States will be subject to the limitations, if any, stated under the Covered Dental Services and paid based on the Out-of-Network reimbursement shown in The Schedule; • replacement of a partial denture, complete denture, fixed bridge, any prosthesis over implant, or the addition of teeth to a partial denture is not covered, unless the replacement is needed due to a Medically Necessary and/or Dentally Necessary extraction of an additional Functioning Natural Tooth while the person is covered under this plan; • replacement of a crown, bridge, onlay, post/post and core, or other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture within the frequency limitation stated under the Covered Dental Services is not covered unless: • the replacement is made necessary by the placement of an original opposing complete denture or the Medically Necessary and/or Dentally Necessary extraction of a Functioning Natural Tooth; or • the crown, bridge, onlay, post/post and core, other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits; • replacement of any amalgam or resin-based composite restoration involving the same surface(s) on the same tooth by the same Dentist or a different Dentist in the same office within the frequency limitation stated under the Covered Dental Services is not covered;
HCDFB-DEX109
06-21
Expenses Not Covered Covered Dental Expenses will not include, and no payment will be made for: • any services not stated under Covered Dental Services and The Schedule;
myCigna.com
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