LifeMap Incentive 10 Exclusions

Exclusions for Individual Incentive 10 Dental Plan

These services and supplies are not covered:

  • Additional procedures to construct new crown under existing partial denture framework
  • Application of desensitizing resin for cervical and/or root surface
  • Bleaching of teeth
  • Collection of cultures and specimens
  • Connector bar or stress breaker
  • Cosmetic/reconstructive services and supplies (certain exceptions apply)
  • Diagnostic casts or study models
  • Duplicate X-rays
  • Endodontic endosseous implants
  • Exfoliate cytology sample collection or brush biopsy
  • Expenses payable by motor vehicle insurance or other liability insurance coverage
  • Experimental/investigational treatments, procedures, and services and supplies
  • Fees, taxes, interest
  • Gold foil restorations
  • Hospitalization for dentistry
  • Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis
  • Incision and drainage of abscess extraoral soft tissue, complicated or non-complicated
  • Indirect pulp capping
  • Interim partial or complete dentures
  • Labial veneers
  • Local anesthesia, sterilization, and supplies billed as separate charges (these procedures are considered inclusive of billed
  • Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth
  • Maxillofacial prosthetic procedures
  • Military service-related conditions: any condition resulting from military service in the armed forces of any country
  • Modification of removable prosthesis following implant surgery
  • Nitrous oxide
  • Non-direct patient care
  • Occlusal analysis and adjustments
  • Occlusal guards
  • Oral hygiene instructions
  • Oral/facial photographic images
  • Orthodontic services, including craniomandibularorthopedic treatment; procedures for tooth movement, regardless of purpose;
    correction of malocclusion; preventive orthodontic procedures; and other orthodontic treatment
  • Pediatric dentures
  • Pin retention in addition to restoration
  • Precision attachments
  • Prescription drugs, including take home prescription drugs, pre-medications, therapeutic drug injections, or supplies
  • Provisional splinting
  • Pulp vitality tests
  • Radical resection of maxilla or mandible
  • Radiographic/surgical implant index
  • Removal of nonodontogenic cyst, tumor or lesion
  • Replacement of lost, stolen or broken dental appliances
  • Self-help, non-dental self-care, training, or instructional programs
  • Services and supplies provided by a family member: services and supplies provided to a member by an immediate family member
  • Surgical procedures for isolation of a tooth with rubber dam
  • Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
  • Treatment for an illness or injury caused by a member’s unlawful instigation and/or active participation in a riot,
    rebellion, war or illegal act
  • Treatment of simple or compound fractures of the mandible
  • Treatment of Temporomandibular Joint Dysfunction
  • Unspecified implant procedures
  • Work-related injuries
Exclusions for Individual Managed Care Dental Plan

These services and supplies are not covered:

  • Aesthetic dental procedures and complications arising out of such services
  • Benefits not stated
  • Charges by any person other than a participating provider except as
    otherwise indicated in the policy
  • Cosmetic/reconstructive services and supplies (certain exceptions apply)
  • Coverage available under any federal, state, or other governmental program,
    except where required by law
  • Diagnostic casts or study models
  • Endodontics, bridges, crowns, and other prosthetic devices or services if
    treatment was started or ordered prior to the member’s effective date or
    delivered more than 60 days after the member’s coverage under this policy
    has terminated
  • Excision of a tumor; biopsy of soft or hard tissue;
    removal of a cyst
  • Experimental/investigational treatments, procedures, services and supplies
  • Extraction of permanent teeth for tooth guidance procedures; procedures for
    tooth movement
  • Full-mouth reconstruction
  • General Anesthesia, except as specified in the Schedule of Covered Services,
    Copays and Coinsurance
  • Habit-breaking or stress-breaking appliances
  • Hospitalization for dentistry
  • Maxillofacial prosthetic services
  • Medication and supply charges
  • Military service-related conditions
  • Motor vehicle coverage and other insurance liability
  • Non-direct patient care
  • Occlusal treatment including complete occlusal adjustments and
    occlusal guards
  • Personalized restorations, precision attachments, and special techniques
  • Repair or replacement of lost, stolen, or broken items
  • Replacement of sound restorations
  • Services and supplies for treatment of an illness or injury caused by riot,
    rebellion, war and illegal acts
  • Services for accidental injury to natural teeth that are provided more than
    12 months after the date of the accident
  • Services or supplies and related exams or consultations that are not within
    the prescribed treatment plan and/or are not recommended and approved a
    participating provider
  • Temporomandibular Joint (TMJ) dysfunction treatment
  • Transseptal fiberotomy
  • Treatment started prior to the member’s effective date under this policy or
    completed after this policy terminates
  • Work-related injuries

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