Search:

General Dental Exclusions for 2008

• Willamette Dental
• DeltaCare
• Uniform Dental Plan

Willamette Dental

The following services are not covered:

1. Dentistry for cosmetic reasons. Cosmetic services include, but are not limited to, laminates, veneers, or tooth bleaching.
2. Restorations or appliances necessary to increase or alter the vertical dimension or to restore the occlusion. Excluded procedures include restoration of tooth structure lost from attrition and restorations for malalignment of teeth.
3. Services or supplies that the plan determines are experimental or investigative.
4. Any drugs or medicines, even if they are prescribed, except as stated in the Prescription Drug Program benefit. This includes analgesics (medications to relieve pain) and patient management drugs, such as pre-medication and nitrous oxide.
5. General anesthesia, intravenous, and inhalation sedation, except that coverage will be provided for general anesthesia services in conjunction with any covered dental procedure performed in a dental office if such anesthesia services are medically necessary because the enrollee is under the age of 7, or physically or developmentally disabled.
6. Hospital or other facility care for dental procedures, including physician services and additional fees charged by the dentist for hospital treatment. However, this exclusion will not apply and benefits will be provided for services rendered during such hospital care, including outpatient charges, if all these requirements are met:
   1. A hospital setting for the dental care must be medically necessary.
   2. Expenses for such care are not covered under the enrollee’s employer-sponsored medical plan.
   3. Prior to hospitalization, a request for preauthorization of dental treatment performed at a hospital is submitted to and approved by the plan. Such request for preauthorization must be accompanied by a physician’s statement of medical necessity.
      
      If hospital or facility care is approved, available benefits will be provided at the same percentage rate as those performed by a participating dental provider, up to the available benefit maximum.
7. Dental services started prior to the date the person became eligible for services under this plan, except as provided for orthodontic benefits for members who were covered under the 2007 Regence BlueShield Columbia Dental Plan immediately prior to being covered under the Willamette Dental Plan.
8. Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident.
9. Expenses incurred after termination of coverage, except expenses for:
   1. Prosthetic devices that are fitted and ordered prior to termination and delivered within 30 days after termination.
   2. Crowns, if the tooth is prepared prior to termination and the crown is seated on the tooth within 30 days after termination.
   3. Root canal treatment, if the tooth canal is opened prior to termination and treatment is completed within 30 days after termination.
10. Missed appointments.
11. Completing insurance forms or reports, or for providing records.
12. Habit-breaking appliances, except as specified under the orthodontia benefit.
13. Full-mouth reconstruction.
14. Replacement of sound filings. (Replacement of sound fillings will not be covered unless recommended by a licensed dentist; preauthorization is required.)
15. Charges for dental services performed by anyone who is not a licensed dentist, registered dental hygienist, denturist, or physician, as specified.
16. Loss or theft of fixed or removable prosthetics (crowns, bridges, full or partial dentures).
17. Orthodontic treatment, orthognathic treatment, and treatment of temporomandibular joint (TMJ) disorders that are not authorized in advance by the plan.

DeltaCare

The following services are not covered:

1. General anesthesia, intravenous, and inhalation sedation, and the services of a special anesthesiologist, except that coverage will be provided for general anesthesia services in conjunction with any covered dental procedure performed in a dental office if such anesthesia services are medically necessary because the enrollee is under the age of 7, or physically or developmentally disabled.
2. Cosmetic dental care. Cosmetic services include, but are not limited to, laminates, veneers, or tooth bleaching.
3. Services for injuries or conditions which are compensable under workers’ compensation or employers’ liability laws, and services which are provided to the eligible person by any federal, state, or provincial government agency or provided without cost to the eligible person by any municipality, county, or other political subdivision, other than medical assistance in this state, under medical assistance RCW 74.09.500, or any other state, under 42 U.S.C., Section 1396a, section 1902 of the Social Security Act.
4. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion; such procedures include restoration of tooth structure lost from attrition, abrasion, or erosion without sensitivity and restorations for malalignment of teeth.
5. Application of desensitizing agents.
6. Experimental services or supplies. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation.
7. Dental services performed in a hospital and related hospital fees. However, this exclusion will not apply and benefits will be provided for services rendered during such hospital care, including outpatient charges, if all these requirements are met:
   1. A hospital setting for the dental care must be medically necessary.
   2. Expenses for such care are not covered under the enrollee’s employer-sponsored medical plan.
   3. Prior to hospitalization, a request for preauthorization of dental treatment performed at a hospital is submitted to and approved by the plan. Such request for preauthorization must be accompanied by a physician’s statement of medical necessity.
      
      If hospital or facility care is approved, available benefits will be provided at the same percentage rate as those performed by a participating dental provider, up to the available benefit maximum.
8. Loss or theft of fixed or removable prosthetics (crowns, bridges, full or partial dentures).
9. Dental expenses incurred in connection with any dental procedure started after termination of eligibility of coverage.
10. Dental expenses incurred in connection with any dental procedure started prior to the enrollee’s eligibility, except for orthodontic services.
11. Cysts and malignancies.
12. Laboratory examination of tissue specimen.
13. Any drugs or medicines, even if they are prescribed. This includes analgesics (medications to relieve pain) and patient management drugs, such as pre-medication and nitrous oxide.
14. Cases which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained or where the prognosis is poor or guarded.
15. Prophylactic removal of impactions (asymptomatic, nonpathological).
16. Specialist consultations for non-covered benefits.
17. Orthodontic treatment which involves therapy for myofunctional problems, TMJ dysfunctions, micrognathia, macroglossia, cleft palate, or hormonal imbalances causing growth and developmental abnormalities.
18. All other services not specifically included on the patient’s copayment schedule as a covered dental benefit.
19. Treatment of fractures and dislocations to the jaw.
20. Dental services received from any dental office other than the assigned dental office, unless expressly authorized in writing by DeltaCare (WDS) or as cited under “Emergency Care or Urgent Care” in DeltaCare’s certificate of coverage.

Uniform Dental Plan

General Limitations

1. Dentistry for cosmetic reasons is not a covered benefit. Cosmetic services include, but are not limited to laminates, veneers, or tooth bleaching.
2. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion; such procedures include restoration of tooth structure lost from attrition, abrasion or erosion and malalignment of teeth.
3. General anesthesia, intravenous, and inhalation sedation are not a covered benefit except that coverage will be provided:
   1. When in conjunction with covered oral surgery, endodontic, and periodontal surgical procedures; and
   2. For general anesthesia services in conjunction with any covered dental procedures performed in a dental office if such anesthesia services are medically necessary because the enrollee is under the age of 7, or physically or developmentally disabled.

General Exclusions

In addition to the specific exclusions and limitations stated elsewhere in the booklet, UDP does not provide benefits for:

1. Application of desensitizing medicaments.
2. Services or supplies that the Uniform Dental Plan determines are experimental or investigative. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation.
3. Any drugs or medicines, even if they are prescribed. This includes analgesics (medications to relieve pain) and patient-management drugs, such as premedication and nitrous oxide.
4. Hospital or other facility care for dental procedures, including physician services and additional fees charged by the dentist for hospital treatment. However, this exclusion will not apply and benefits will be provided for services rendered during such hospital care, including outpatient charges, if all these requirements are met:
   1. A hospital setting for the dental care must be medically necessary.
   2. Expenses for such care are not covered under the enrollee’s employer-sponsored medical plan.
   3. Prior to hospitalization a request for preauthorization of dental treatment performed at a hospital is submitted to and approved by Washington Dental Service. Such request for preauthorization must be accompanied by a physician’s statement of medical necessity.
      
      If hospital or facility care is approved, available benefits will be provided at the same percentage rate as those services performed by a participating dental provider, up to the available benefit maximum.
5. Dental services started prior to the date the person became eligible for services under this plan, except as provided for orthodontic benefits.
6. Services for accidental injury to natural teeth when evaluation of treatment and development of a written plan is performed more than 30 days from the date of the injury. Treatment must be completed within the time frame established in the treatment plan unless delay is medically indicated and the written treatment plan is modified.
7. Expenses incurred after termination of coverage, except expenses for:
   1. Prosthetic devices that are fitted and ordered prior to termination and delivered within 30 days after termination.
   2. Crowns, if the tooth is prepared prior to termination and the crown is seated on the tooth within 30 days after termination.
   3. Root canal treatment, if the tooth canal is opened prior to termination and treatment is completed within 30 days after termination.
8. Missed appointments.
9. Completing insurance forms or reports, or for providing records.
10. Habit-breaking appliances, except as specified under the orthodontia benefit.
11. Full-mouth restoration or replacement of sound fillings. (Replacement of sound fillings will not be covered unless recommended by a licensed dentist, and preauthorization is required.)
12. Charges for dental services performed by anyone who is not a licensed dentist, registered dental hygienist, denturist, or physician, as specified.
13. Services or supplies that are not listed as covered.
14. Treatment of congenital deformity or malformations.
15. Replacement of lost or broken dentures or other appliances.
16. Services for which an enrollee has a contractual right to recover cost, whether a claim is asserted or not, under automobile, medical, personal injury protection, homeowner’s or other no-fault insurance.
17. In the event an eligible person fails to obtain a required examination from a Washington Dental Service-appointed consultant dentist for certain treatments, no benefits will be provided for such treatment.

Washington Dental Service shall have the discretionary authority to determine whether services are covered benefits in accordance with the general limitations and exclusions shown in the contract, but it shall not exercise this authority arbitrarily or capriciously or in violation of the contract.