We will not pay Dental Insurance benefits for charges incurred for:
1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate). 5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: • scaling and polishing of teeth; or • fluoride treatments. For NY Sitused Groups, this exclusion does not apply.
6. Services or appliances which restore or alter occlusion or vertical dimension. 7. Restoration of tooth structure damaged by attrition, abrasion or erosion. 8. Restorations or appliances used for the purpose of periodontal splinting. 9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. 11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work. 12. Missed appointments. 13. Services • covered under any workers’ compensation or occupational disease law; • covered under any employer liability law; • for which the employer of the person receiving such services is not required to pay; or • received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. For North Carolina and Virginia Sitused Groups, this exclusion does not apply. 14. Services paid under any worker’s compensation, occupational disease or employer liability law as follows: • for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act; • or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law. This exclusion only applies for North Carolina Sitused Groups. 15. Services: • for which the employer of the person receiving such services is required to pay; or • received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. This exclusion only applies for North Carolina Sitused Groups. 16. Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law. This exclusion only applies for Virginia Sitused Groups. 17. Services: • for which the employer of the person receiving such services is not required to pay; or • received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital. This exclusion only applies for Virginia Sitused Groups. 18. Services covered under other coverage provided by the Employer.
19. Temporary or provisional restorations. 20. Temporary or provisional appliances. 21. Prescription drugs. 22. Services for which the submitted documentation indicates a poor prognosis. 23. The following when charged by the Dentist on a separate basis: • claim form completion; • infection control such as gloves, masks, and sterilization of supplies; or •
local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. 24. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food. For NY Sitused Groups, this exclusion does not apply. 25. Caries susceptibility tests. 26. Other fixed Denture prosthetic services not described elsewhere in this certificate.
27. Precision attachments, except when the precision attachment is related to implant prosthetics. 28. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it. 29. Fixed and removable appliances for correction of harmful habits. 1
30. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards. 1 31. Diagnosis and treatment of temporomandibular joint ( TMJ ) disorders. This exclusion does not apply to residents of Minnesota. 1 32. Orthodontic services or appliances. 1 33. Repair or replacement of an orthodontic device. 1 34. Duplicate prosthetic devices or appliances.
200 Park Ave., New York, NY 10166 © 2022 MetLife Services and Solutions, LLC L0122019082[exp0323][xNM]
DN-GCERT-GOLD Multioption Dental Benefit Summary
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