• procedures that are deemed to be medical services or are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured basis; • any charges, including ancillary charges, for services and supplies received from a hospital, outpatient facility, ambulatory surgical center or similar facility; • charges incurred due to injuries which are intentionally self- inflicted; • charges for or in connection with an injury or illness arising out of, or in the course of any employment for wage or profit; • charges for or in connection with an injury or illness which is covered under any workers’ compensation or similar law; • charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition; • services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared; • consultations and/or evaluations associated with services that are not covered; • cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) which may include but is not limited to the following: bleaching (tooth whitening), in office and/or at home, enamel microabrasion, odontoplasty, facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth will always be considered cosmetic; • replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances, if orthodontics is covered) that have been lost, stolen, or damaged due to patient abuse, misuse, or neglect; • procedures, services, supplies, restorations, or appliances (except complete dentures), whose sole or primary purpose is to change or maintain vertical dimension; • procedures, services, supplies, restorations or appliances whose main purpose is to diagnose or treat jaw joint problems, including dysfunction of the temporomandibular joint and craniomandibular disorders, or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint; • the restoration of teeth which have been damaged by erosion, attrition, abfraction or abrasion; • bite registration or bite analysis; • precision or semi-precision attachments;
• any procedure, service, supply or appliance used primarily for the purpose of splinting; • porcelain, ceramic, resin, or acrylic materials on crowns or pontics on, or replacing the upper or lower first, second and/or third molars; • services to correct congenital malformations, including the replacement of congenitally missing teeth; • procedures, restorations, appliances or services to stabilize periodontally involved teeth; • myofunctional therapy; • replacement of a partial denture or complete denture which can be made serviceable; • prescription drugs; • treatment of jaw fractures and/or orthognathic surgery; • the treatment of cleft lip and cleft palate; • charges for sterilization of equipment, infection control processes and procedures, disposal of medical waste or other requirements mandated or recommended by the Centers for Disease Control and Prevention (CDC), OSHA or other regulatory agencies; We consider these to be incidental to and part of the charges for services provided and not separately chargeable; • charges for travel time; transportation costs; • personal supplies, including but not limited to toothbrushes, rotary toothbrushes, floss holders, and water irrigation devices; • oral hygiene instructions, tobacco counseling, substance use counseling, and nutritional counseling; • charges for broken appointments; completion of claim forms; duplication of radiographic images and/or exams required by a third party; • charges for treatment or surgery that does not meet plan guidelines; • general anesthesia or intravenous sedation when used for the purposes of anxiety control or patient management; • indirect pulp capping on the same date of service as a permanent restoration, We consider this to be incidental to and part of the charges for services provided and not separately chargeable; • additional/incremental costs associated with optional/elective orthodontic materials including but not limited to: ceramic, clear, or lingual brackets, or other cosmetic appliances including clear aligners; orthognathic surgery and associated incremental costs; appliances to guide minor tooth movement; and services which are not typically included in Orthodontic Treatment. These services
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