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Acupuncture therapy.
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Adjustment of a denture or a bridgework that is made within six months after insertion by the same dentist who inserted it.
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Any duplicate appliance or prosthetic device, except partial dentures or bridgework that cannot be made serviceable.
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Charges for or in connection with services or supplies that are, as determined by the Claims Administrator, to be experimental or investigational. A drug, device, procedure, or treatment will be determined to be experimental or investigational, and therefore not covered, if:
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there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;
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approval is required by the FDA, and FDA approval has not been granted for marketing;
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a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or
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the written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure, or treatment, or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental, investigational or for research purposes.
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Charges for broken appointments or for completing dental forms.
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Charges for crowns and fillings not specified as covered under the Plan.
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Cosmetic surgery, treatment, services, or supplies; however such items will be covered if required for the treatment or correction of a congenital defect of a newborn dependent child eligible for benefits under this Plan.
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Facings or veneers on molar crowns or molar false teeth.
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Implantology.
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Initial installation of a denture or bridgework to replace one or more natural teeth lost before the individual became covered under this Plan. This exclusion does not apply under the HDS-administered Dental Plans.
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Instructions for oral care, such as hygiene or diet.
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Myofunctional therapy or correction of harmful habits.
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Periodontal splinting.
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Prescription drugs prescribed by a dentist. However, individuals covered under a FlexSolutions Medical Plan may receive coverage for drugs prescribed by a dentist under the applicable medical plan's prescription drug benefit program. For information regarding the prescription drug benefits, refer to the prescription drug information provided within About The HMSA Medical Plans, About The CIGNA Medical Plans, or About The Kaiser HMO as applicable.
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Procedures, appliances, restorations, or replacement of structure loss from caries (decay), unless necessary to alter, restore or maintain occlusion. Such procedures include, but are not limited to, increasing vertical dimension, equilibration, periodontal splinting, restoration of tooth structure lost from attrition, restorations for tooth malalignment, and gnathological recordings.
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Repair or replacement of an orthodontic appliance.
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Replacement of a lost, missing or stolen crown, bridge or denture.
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Routine exams or other preventive services and supplies, except those as specifically stated as covered under What The Plans Cover.
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Services or supplies received by an individual before he or she becomes covered under this Plan.
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Services not performed by a dentist; however, certain services (namely cleaning and scaling of teeth, and fluoride treatments) provided by a licensed dental hygienist are covered when supervised and billed by a dentist.
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Services or supplies that are covered by any workers' compensation, occupational disease or employers' liability laws; or that any employer is required by law to furnish, in whole or in part. Also, any services or supplies received through a medical department or similar facility maintained by the covered individual's employer, or that are provided as a benefit under any other plan sponsored by the Company.
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Services or supplies received by a covered individual for which no charge would have been made in the absence of this coverage or for which the covered individual is not required to pay.
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Services or supplies deemed experimental in terms of generally accepted dental standards.
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Services or supplies received as a result of a dental disease, defect or injury due to an act of war, or a warlike act in time of peace.
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Services or supplies furnished by a family member.
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Sterilization supplies.
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Treatment for TMJ or skeletal disharmonies of the jaw.
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Use of materials to prevent decay (other than fluorides and sealant material for a dependent child subject to the age restrictions outlined under What The Plans Cover). Note that sealants are not covered under HDS.
