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; • services associated with the diagnosis, placement, treatment, repair, removal or replacement of a dental implant, or any other services related to implants, unless covered by Your specific plan; • 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; • Orthodontic Treatment; • 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; • diagnostic casts, diagnostic models or study models; • 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; • endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis; • harmful habits treatment; • 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
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