Download pdf - FEDVIP Select High - 710xs - Dominion National · FEDVIP Select High - 710xs Description of Benefits & Member Copayments All fees exclude the cost of noble and precious metals. An

D2980-83 Crown, inlay, onlay or veneer repair................................. 72 D2990 Resininfiltration/smoothsurface ...................................... 12

PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular ...................... 455 D5130/40 Immediatedenture-maxillary/mandibular ..................... 511 D5211/12 Maxillary/mandibularpartialdenture-resinbase .......... 306 D5213/14 Maxillary/mandibularpartialdenture-castmetal .......... 549 D5281 Rem.unilateralpartialdenture-onepiececastmetal ... 281 D5410/11 Adjustcompletedenture-maxillary/mandibular ................ 9 D5421/22 Adjustpartialdenture-maxillary/mandibular ..................... 9 D5510/5610 Repairbrokendenturebase(complete/resin) .................. 20 D5520 Replacemissingorbrokenteeth-completedenture ...... 20 D5620 Repaircastframework ..................................................... 20 D5630 Repairorreplacebrokenclasp ........................................ 24 D5640 Replacebrokenteeth-pertooth ..................................... 20 D5650/60 Addtoothorclasptoexistingpartialdenture ................... 20D5670/71 Replaceallteethandacryliconcastmetalframework- maxillary/mandibular ................................................... 109 D5710/11 Rebasecompletemaxillary/mandibulardenture .............. 55 D5720/21 Rebasemaxillary/mandibularpartialdenture ................... 55 D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ...33 D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) ... 33D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ........ 49 D5760/61 Relinemaxillary/mandibularpartialdenture(lab) ............. 49 D5850/51 Tissueconditioning-maxillary/mandibular ...................... 16 BRIDGE/PONTICSD6010 Endostealimplant-surgicalplacement ......................... 830 D6011 Secondstageimplantsurgery ...................................... 200D6013 Surgicalplacementofminiimplant ............................... 277D6055 Connectingbar-implantorabutmentsupported ........... 780 D6056 Prefabr.abutment-incl.modificationandplacement .... 220 D6057 Customfabricatedabutment-incl.modification/placement ... 315 D6058 Abutmentsupportedporcelain/ceramiccrown ............... 547 D6059 Abutmentporc/metalcrown-highnoblemetal ................ 544 D6060 Abutmentporc/metalcrown-pred.basemetal ............... 485 D6061 Abutmentporc/metalcrown-noblemetal ...................... 512 D6062 Abutmentsupp.casthighnoblemetalcrown ................ 536 D6063 Abutmentsupp.castpredom.metalcrown .................... 477 D6064 Abutmentsupp.castnoblemetalcrown ........................ 499 D6065 Implantsupp.porcelain/ceramiccrown .......................... 572 D6066 Implantporc/metalcrown-titanium/alloy/noble ............... 575D6067 Implantsupp.metalcrown- titanium/titaniumalloy/highnoblemetal ..................... 556 D6068 Abutmentsupp.retainerforporc./ceramicFPD ............. 507D6069 Abutmentsupp.retainerforporc.fused tohighnoblemetalFPD ............................................ 542D6070 Abutmentsupp.retainerforporc.fused topredom.basemetalFPD ....................................... 447 D6071 Abutmentsupp.retainerforporc.fusedtonoblemetalFPD .... 453 D6072 Abutmentsupp.retainerforcasthighnoblemetalFPD .... 507 D6073 Abutmentsupp.retainerforcastpredom.basemetalFPD .. 481 D6074 Abutmentsupp.retainerforcastnoblemetalFPD ........ 487 D6075 Implantsupp.retainerforceramicFPD ......................... 562 D6076 Implantsupp.retainerforporcelainfused totitanium/titaniumalloy/highnoblemetalFPD ......... 529D6077 Implantsupp.retainerforcast titanium/titaniumalloy/highnoblemetalFPD ............. 560 D6080 Implantmaintenanceprocedures ..................................... 39D6081 Scalinganddebridementinthepresenceofinflammation ormucositisofasingleimplant,includingcleaningof theimplantsurfaces,withoutflapentryandclosure .........23D6090 Repairimplantprosthesis .............................................. 233 D6091 Replacementofsemi-precisionorprecisionattachment ... 22 D6094 Abutmentsupp.crown-titanium ................................... 355 D6095 Repairimplantabutment ................................................ 251 D6100 Implantremoval ............................................................. 155 D6194 Abutmentsupp.retainercrownforFPD-titanium ......... 476 D6210-14 Pontic-castmetal ......................................................... 366 D6240/41/42 Pontic-porcelainfusedmetal ........................................ 380 D6245 Pontic-porcelain/ceramic .............................................. 417 D6545 Retainer-castmetalforresinbondedfixedprosthesis ... 174 D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis ... 256

D9439 Officevisit ........................................................................ 10 DIAGNOSTIC/PREVENTIVEPreventionReward:EachfamilymemberenrolledwithDominionwhoreceivescleaningsduringtheplanyearwillbereimbursedfortheir$10officevisitcopaymentsmadetothedentistatthetimeofservice(uptotwocleaningsperplanyear–atotalreimbursementofupto$20).Dominionwillsubmitacheckforthereimbursement(s)totheprimarysubscriberattheendoftheplanyear.D0120 Periodicoraleval-establishedpatient .............................. 0 D0140 Limitedoraleval-problemfocused ................................... 0 D0145 Oralevalforapatientunder3yearsofage ....................... 0 D0150 Comprehensiveoraleval-neworestablishedpatient ...... 0 D0160 Detailedandextensiveoraleval-problemfocused .......... 0 D0180 Comp.periodontaleval-neworestablishedpatient ......... 0 D0210 Intraoral-completeseries(includingbitewings) ................ 0 D0220 Intraoral-periapicalfirstfilm .............................................. 0 D0230 Intraoral-periapicaleachadd.film .................................... 0D0240 Intraoral-occlusalfilm ....................................................... 0 D0250 Extraoral-firstfilm ............................................................. 0 D0270-74 Bitewingx-rays-1to4films .............................................. 0 D0277 Verticalbitewings-7to8films ........................................... 0 D0330 Panoramicfilm ................................................................... 0 D0425 Cariessusceptibilitytests ................................................... 0 D1110 Prophylaxis(cleaning)-adult ............................................. 0 D1110* Additionalcleaning(expectingmothersorDiabetics) ...... 40 D1120 Prophylaxis(cleaning)-child ............................................. 0 D1206 Topicalfluoridevarnishformod/highriskcariespatients ... 0 D1208 Topicalapplicationoffluoride ............................................. 0 D1351 Sealant-pertooth ............................................................. 0 D1352 Prevresinrest.mod/highcariesrisk–perm.tooth ............ 0 SPACEMAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral ................. 0 D1515/25 Spacemaintainer-fixed/removable-bilateral ................... 0 D1550 Re-cementationofspacemaintainer ................................. 0D1575 Distalshoespacemaintainer–fixed–unilateral ............... 0

RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm. ............................. 0 D2150 Amalgam-twosurfaces,prim.orperm. ............................ 0 D2160 Amalgam-threesurfaces,prim.orperm. ......................... 0 D2161 Amalgam->=4surfaces,prim.orperm. ........................... 0 RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-basedcomposite-onesurface,anterior ............... 16 D2331 Resin-basedcomposite-twosurfaces,anterior .............. 20 D2332 Resin-basedcomposite-threesurfaces,anterior ........... 24 D2335 Resin-basedcomposite->=4surfaces,anterior ............. 24 D2391 Resin-basedcomposite-onesurface,posterior ............. 18 D2392 Resin-basedcomposite-twosurfaces,posterior ............ 23 D2393 Resin-basedcomposite-threesurfaces,posterior ......... 28 D2394 Resin-basedcomposite->=4surfaces,posterior ........... 33

D2951 Pinretention-pertooth,inadditiontorestoration ............. 5

CROWN & BRIDGED2510 Inlay-metallic-onesurface .......................................... 247 D2520 Inlay-metallic-twosurfaces ......................................... 282 D2530 Inlay-metallic-threeormoresurfaces ......................... 290 D2542 Onlay-metallic-twosurfaces ......................................... 338 D2543 Onlay-metallic-threesurfaces ...................................... 363 D2544 Onlay-metallic-fourormoresurfaces ........................... 380 D2740 Crown-porcelain/ceramicsubstrate ............................. 417 D2750/51/52 Crown-porcelainfusedmetal ....................................... 380 D2780/81/82 Crown-3/4castwithmetal ............................................ 260 D2783 Crown-3/4porcelain/ceramic ....................................... 290 D2790-94 Crown-fullcasthighnoblemetal .................................. 366 D2910/20 Recementinlay,onlay/crownorpartialcoveragerest. .... 12 D2930/31 Prefab.stainlesssteelcrown-prim./perm.tooth ............. 70 D2941 Interimtherapeuticrestoration,primarydentition .............. 0D2950 Corebuildup,includinganypins ...................................... 90D2954 Prefab.postandcoreinadditiontocrown ..................... 112

FEDVIP Select High - 710xsDescription of Benefits & Member Copayments

Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.

ADA MEMBERCODE BENEFIT COPAYMENT(S)


2018

D6601 Inlay-porc./ceramic,>=3surfaces ................................ 228 D6604 Inlay-castpredominantlybasemetal,twosurfaces ..... 152 D6605 Inlay-castpredominantlybasemetal,>=3surfaces ..... 194 D6613 Onlay-castpredominantlybasemetal,>=3surfaces ... 213 D6740 Crown-porcelain/ceramic ............................................. 417 D6750/51/52 Crown-porcelainfusedmetal ....................................... 380 D6780/81/82 Crown-3/4castmetal ................................................... 260 D6783 Crown-3/4porc./ceramic .............................................. 290 D6790-94 Crown-fullcastmetal ................................................... 366 D6930 Recementfixedpartialdenture ........................................ 17 D6980 Fixedpartialdenturerepair,byreport ............................ 124 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain ............... 35 D9223 Deepsedation/generalanesthesia –each15minuteincrement ......................................... 87D9243 Intravenousmoderate(conscious)sedation/analgesia –each15minute ......................................................... 81D9310 Consultation(diagnosticservicebynontreatingdentist) .... 0 D9440 Officevisit-afterregularlyscheduledhours .................... 10 D9610 Therapeuticdruginjection,byreport ............................... 20 D9612 Therapeuticparenteraldrugs,2ormoreadminis.,diff.meds. .. 31D9930 Treatmentofcomplications(post-surgical) ...................... 42D9941 Fabricationofathleticmouthguard ................................... 42D9972/73/75 INTERNAL/EXTERNALBLEACHING-15%DISCOUNT FROMPARTICIPATINGDENTIST’SUCRFEED9974 Internalbleaching-pertooth ........................................... 84 D9986 Missedappointment ......................................................... 50 D9999 Unspecifiedadjunctiveprocedure,byreport ...................... 0 D9995 Teledentistry–synchronous;real-timeencounter (whenavailable) .................................................................20D9996 Teledentistry–asynchronous;informationstoredand forwardedtodentistforsubsequentreview (whenavailable) .................................................................20

ENDODONTICS1

D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ................ 8 D3220 Therapeuticpulpotomy(excl.finalrestor.) ....................... 21 D3221 Pulpaldebridement,prim.andperm.teeth ...................... 22 D3222 Partialpulp.forapexogenesis- perm.teethw/incomp.rootdevelop. ........................... 28D3230/40 Pulpaltherapy-anterior/posterior, prim.tooth(excl.finalrest.) .......................................... 28 D3310 Endodontictherapy,anteriortooth ................................. 260 D3320 Endodontictherapy,bicuspidtooth ................................ 332 D3330 Endodontictherapy,molar ............................................. 416 D3346 Retreatofprev.rootcanaltherapy,anterior ................... 290 D3347 Retreatofprev.rootcanaltherapy,bicuspid .................. 371D3348 Retreatofprev.rootcanaltherapy,molar ...................... 438D3351 Apexification/recalcification–initialvisit ....................... 109 D3352 Apexification/recalcification-interimmed.replacement . 319 D3353 Apexification/recalcification-finalvisit ........................... 243 D3355 Pulpalregeneration-initialvisit .................................... 109D3356 Pulpalregeneration-interimmedicationreplacement .. 319D3357 Pulpalregeneration-completionoftreatment .............. 150D3410 Apicoectomy,anterior..................................................... 238 D3421 Apicoectomy,bicuspid(firstroot) .................................... 268 D3425 Apicoectomy,molar(firstroot) ....................................... 283 D3426 Apicoectomy-(eachadd.root) ...................................... 112 D3427 Periradicularsurgeryw/oapicoectomy ......................... 171D3428 Bonegraftinconj.w/periradicularsurg., pertooth,singlesite ................................................... 369D3429 Bonegraftinconj.w/periradicularsurg., add.contiguoustooth,samesite ............................... 288D3430 Retrogradefilling-perroot .............................................. 81D3431 Biologicmaterialstoaidsoft/osseoustissue regen.inconj.w/periradicularsurg. .......................... 189D3432 Guidedtissueregen.,resorbablebarrier, persite,inconj.w/periradicularsurg. ....................... 379D3450 Rootamputation-perroot ............................................. 156 D3920 Hemisection,notinc.rootcanaltherapy ........................ 145 PERIODONTICS1

D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad. . 205 D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad. ...... 70 D4212 Gingivectomyorgingivoplasty-w/rest.proc.,pertooth ... 30D4240 Gingivalflapproc.,inc.rootplaning- >3cont.teeth,perquad ............................................. 257D4241 Gingivalflapproc,inc.rootplaning- <=3cont.teeth,perquad ............................................. 74

FEDVIP Select High - 710xs

D4249 Clinicalcrownlengthening-hardtissue .......................... 341 D4260 Osseoussurgery->3cont.teeth,perquad................... 422 D4261 Osseoussurgery-<=3cont.teeth,perquad ................ 282 D4268 Surgicalrevisionproc.,pertooth ................................... 258 D4270 Pediclesofttissuegraftprocedure ................................. 381D4273 Subepithelialconnectivetissuegraftproc. (incl.donorsitesurgery) ............................................ 474 D4275 Softtissueallograft ........................................................ 394 D4276 Comb.connectivetissue/doublepediclegraft,pertooth ....432D4277 Freesofttissuegraftprocedure, firstoredentuloustoothpositioninagraft ................. 420D4278 Freesofttissuegraftprocedure,eachadd.contiguous oredentuloustoothpositioninagraftsite ................... 80 D4341 Perioscalingandrootplaning->3contteeth,perquad. .. 31 D4342 Perioscalingandrootplaning-<=3teeth,perquad ...... 23D4346 Scalinginpresenceofgeneralizedmoderateorsevere gingivalinflammation–fullmouth,afteroralevaluation ...32 D4355 Fullmouthdebridement ................................................... 64 D4381 Localizeddeliveryofchemotherapeuticagents ................. 7 D4910 Periodontalmaintenance ................................................. 16 D9940 Occlusalguard,byreport ............................................... 191 ORAL SURGERY1

D7111 Extraction,coronalremnants-deciduoustooth ............... 36 D7140 Extraction,eruptedtoothorexposedroot ........................ 47 D7210 Eruptedtoothreq.bonecut ............................................. 86 D7220 Removalofimpactedtooth-softtissue ......................... 106 D7230 Removalofimpactedtooth-partiallybony .................... 136 D7240 Removalofimpactedtooth-completelybony ............... 160 D7241 Removalofimpactedtooth- completelybony,withunusualsurg.complications ... 178 D7250 Removalofresidualtoothroots ....................................... 90 D7251 Coronectomy–intentionalpartialtoothremoval .............. 90 D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth .. 137 D7280 Exposureofanuneruptedtooth ....................................... 63 D7310 Alveoloplastyinconj.withext.-4ormoreteeth,perquad ... 28D7311 Alveoloplastyinconj.w/extractions- 1-3teeth/toothspaces,perquad. .............................. 24 D7320 Alveoloplastynotinconj.withextractions- 4ormoreteeth,perquad ............................................ 34D7321 Alveoloplastynotinconj.w/extractions- 1-3teeth/toothspaces,perquad. .............................. 28 D7471 Removalofexostosis ....................................................... 61 D7510 Incisionanddrainageofabscess-intraoralsofttissue ... 24 D7910 Sutureofrecentsmallwoundsupto5cm ....................... 10 D7921 Collect-applyautologousproduct ................................... 35 D7971 Excisionofpericoronalgingiva ........................................ 23 D7999 Unspecifiedoralsurgeryprocedure,byreport ................... 0 ORTHODONTICSD8010 Limitedortho.treatment-primarydentition ................. 1045 D8020 Limitedortho.treatment-transitionaldentition ............. 1236 D8030 Limitedortho.treatment-adolescentdentition ............ 1664 D8050 Interceptiveortho.treatment-primarydentition .......... 1568 D8060 Interceptiveortho.treatment-transitionaldentition ..... 1508 D8070* Comp.ortho.treatment-transitionaldentition ............. 3304 D8080* Comp.ortho.treatment-adolescentdentition ............. 3422 D8090* Comp.ortho.treatment-adultdentition ...................... 3658 D8210 Removableappliancetherapy ....................................... 620D8220 Fixedappliancetherapy ................................................. 630D8660 Pre-orthodontictreatmentvisit ......................................... 78 D8670 Periodicortho.treatmentvisit(aspartofcontract) ........ 118D8680 Ortho.retention(rem.ofappl.andplacementofretainer(s)) .... 157 D8690 Ortho.treatment(alternativebillingtoacontractfee) .... 504

* Invisalign - 15% discount from participating dentist’s UCR fee.

OnlycurrentADACDTcodesareconsideredvalidbyDominionDentalServices,Inc.

Current Dental Terminology © American Dental Association.

1Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. Referrals to a specialist must be made by a member’s Participating General Dentist. See Plan Exclusion #13.



Plan Exclusions1. ServiceswhicharecoveredunderMedicare,worker’scompensationoremployer’sliabilitylaws.2. Serviceswhicharenotnecessaryforthepatient’sdentalhealthasdeterminedbythePlan.3. Cosmetic,electiveoraestheticdentistryexceptasrequiredduetoaccidentalbodilyinjurytosoundnaturalteethasdeterminedbythePlan.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Serviceswithrespecttomalignancies,cystsorneoplasms,hereditary,congenital,anodontic,mandibularprognathismordevelopment malformationswhere,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic,war,actsofwar,whetherdeclaredorundeclared.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withthe exceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder).13. ServicesperformedbyaParticipatingSpecialistwithoutareferralfromaParticipatingGeneralDentist(withtheexceptionof orthodontics).14. Electivesurgeryincluding,butnotlimitedto,extractionofnon-pathologic,asymptomaticimpactedteeth.15. Plaquecontrolprograms,oralhygieneinstruction,anddietaryinstructions.16. Nitrousoxideandoralsedation.


Plan Limitations1. Two(2)evaluationsarecoveredpercalendaryearincludingamaximumofone(1)comprehensiveevaluation.Alloralevaluations willbeconsideredintegralwhenprovidedonthesamedateofservicebythesamedentist.2. One(1)problemfocusedexamiscoveredpercalendaryear,perpatient.3. Two(2)teethcleanings(prophylaxis)arecoveredpercalendaryear,perpatient(one(1)additionalcleaningiscoveredduringpregnancy andfordiabeticpatients).Periodontalscalinginthepresenceofgingivalinflammationisconsideredtobearoutineprophylaxisandpaid assuch.4. Two(2)topicalfluoridesorfluoridevarnishesarecoveredpercalendaryear,perpatient.5. Two(2)bitewingx-raysarecoveredpercalendaryear,perpatient.6. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeverythree(3)years,perpatient.7. One(1)sealantpertoothiscoveredper36months,uptoage18(limitedtopermanent1stand2ndmolars).Sealantswitharestoration onsamedateofserviceareconsideredintegral.8. Distalshoespacemaintainerlimitedtoonceperlifetime.9. Replacementofafillingiscoveredifitismorethantwo(2)yearsfromthedateoforiginalplacement.10. Replacementofabridge,crownordentureiscoveredifitismorethanfive(5)yearsfromthedateoforiginalplacement.11. Crown,implantandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan.Additional crown,implantorbridgeunits,beginningwiththesixthunit,areavailableattheprovider’sUsual,Customary,andReasonable(UCR) fee,minus25%.12. One(1)reliningandrebasingofdenturesiscoveredevery36months,perpatient.13. Retreatmentofrootcanaliscoveredifitismorethantwo(2)yearsfromtheoriginaltreatment.14. Pulpotomiesareconsideredintegralwhenperformedbythesamedentistwithina45-dayperiodpriortothecompletionofrootcanal therapy.15. One(1)rootplaningorscalingiscoveredevery24monthsperquadrant,perpatient.Periodontalscalingandrootplaningprovidedwithin 24monthsofperiodontalscalingandrootplaning,orperiodontalsurgicalprocedures,inthesameareaofthemouthisnotcovered.16. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1110/D1120,limitedtooncepertwoyears.17. One(1)fullmouthdebridementiscoveredperlifetime,perpatient.18. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthree(3)teethperquadrantoratotalof12teethforallfour(4)quadrants pertwelve(12)months.Musthavepocketdepthsoffive(5)millimetersorgreater.19. One(1)periodontalsurgeryofanytype,includinganyassociatedmaterial,iscoveredevery36monthsperquadrantorsurgicalsite.20. Periodontalmaintenanceafteractivetherapyiscoveredtwo(2)timespercalendaryear,within24monthsafterdefinitiveperiodontal therapy.21. Stainlesssteelcrowns(D2930,D2931)arecoveredthroughage14,orwhenplacedasaresultofaccidentalinjuryandonepertooth,per lifetime.22. Onlays,crowns,andpostsandcoresformembers12yearsofageoryoungerareexcludedfromcoverage,unlesspre-approvedby Plan.Castpostsandcores(D2952)areprocessedasanalternatebenefitofaprefabricatedpostandcore.Postsareeligibleonlywhen providedaspartofacrownbuilduporimplantandareconsideredintegraltothebuilduporimplant.23. Fixedpartialdentures,buildupsandpostsandcoresformembersunder16yearsofagearenotcoveredunlessapprovedbyPlan.24. Surgicalperiodontalproceduresorscalingandrootplaninginthesameareaofthemouthwithin24monthsofagingivalflapprocedure arenotcovered.25. Osseoussurgeryisnotcoveredwhenprovidedwithin24monthsofosseoussurgeryinthesameareaofthemouth.26. Surgicalrevisionprocedure(D4268)isconsideredintegraltoallotherperiodontalprocedures.27. One(1)scalinganddebridementinthepresenceofinflammationormucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure,pertwo(2)years.28. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime.29. Removalofimpactedthirdmolarsinpatientsunderage15andoverage30isnotcoveredunlessapprovedbythePlan.30. Deepsedation/generalanesthesiaandintravenousconscioussedationarecovered(byreport)onlywhenprovidedinconnectionwith acoveredprocedure(s)whendeterminedtobemedicallyordentallynecessaryfordocumentedhandicappedoruncontrollablepatientsor justifiablemedicalordentalconditions31. Occlusalguardsarecoveredbyreportforpatients13yearsofageorolderwhenthepurposeoftheocclusalguardisforthetreatment ofbruxismordiagnosesotherthantemporomandibularjointdysfunction(TMJD).Occlusalguardsarelimitedtoone(1)per12consecutive monthperiod.32. Athleticmouthguardsarelimitedtoone(1)per12consecutivemonthperiod.33. TheInvisalignsystemisadiscountedbenefitthatappliestoD8070,D8080andD8090.Additionalcostsincurredwillbecomethepatient’s responsibility.34. Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwo(2)percalendaryear(whenavailable).
