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Charges for canceled appointments
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Claims submitted more than 12 months after the date of rendition of the service
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Experimental procedures
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Hospital costs or any additional fees charged by the dentist because the patient is hospitalized
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Periodontal splinting, including crowns or bridgework for splinting
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Prescribed drugs, pre-medications or analgesia (nitrous oxide)
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Separate charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgical services performed in a dental office. Separate charges for anesthesia when used for restorative procedures are not covered
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Services covered under workers' compensation or employer's liability laws and services covered by any federal, state, county, municipality or other governmental agency
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Services for cosmetic reasons
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Services for plaque control, oral hygiene, or dietary instructions
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Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services include, but are not limited to, increasing vertical dimension, equilibration, and periodontal splinting
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Services for repair or replacement of an orthodontic appliance furnished under the plan
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Services for the application of fluoride for children over the age of 14 or adults
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Services for the application of sealants for children over the age of 18 or adults
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Services started prior to the date the individual became eligible for services under the plan
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Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic reasons; including, but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis and disturbance of the temporomandibular joint
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Temporary devices.
