• 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 will be identified on a case-by-case basis. This exclusion applies when orthodontics is covered under Your plan; • endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis; • intentional root canal treatment in the absence of injury or disease solely to facilitate a restorative procedure; • services to the extent You or Your enrolled Dependent(s) are compensated under any group medical plan; • house/extended care facility calls; hospital calls; office visits for observation (during regularly scheduled hours) when no other services are performed; office visits after regularly scheduled hours; and case presentations;
• procedures performed by a Dentist who is a member of the Covered Person’s family except in the case of a dental emergency when no other Dentist is available. (Covered Person’s family is limited to a Spouse, siblings, parents, children, grandparents, and the Spouse’s siblings and parents); • dental services that do not meet commonly accepted dental standards; • replacement of teeth beyond the normal adult dentition of thirty-two (32) teeth; • services not included in The Schedule, unless We agree to accept such expense as a Covered Dental Expense, in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result; • to the extent that You or any of Your Dependents are in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; • charges in excess of the Maximum Reimbursable Charge allowances; • procedures for which a charge would not have been made if the person had no insurance or for which the person is not legally required to pay. For example, if We determine that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of the Copayment, Deductible, and/or Coinsurance amount(s) You are required to pay for a Covered Dental Service (as shown on The Schedule) without Our express consent, We shall have the right to deny the payment of benefits in connection with the Covered Dental Service, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that You remain responsible for any amounts that Your plan does not cover. We shall have the right to require You to provide proof sufficient to Us that You have made Your required cost share payment(s) prior to the payment of any benefits by Us. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge You or charged You at an In-Network benefits level or some other benefits level not otherwise applicable to the services received; • charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law;
myCigna.com
18
Made with FlippingBook flipbook maker