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; • 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.
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; • 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
HCDFB-DEX109
06-21
myCigna.com
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