Delta Dental Defender

EXCLUSIONS THAT APPLY TO DIAGNOSTIC SERVICES:

1. Pulp vitality tests billed in conjunction with any service except for an emergency exam or palliative treatment are not a covered benefit.
2. Panoramic x-ray for a patient under age 6 is not a covered benefit.

EXCLUSIONS THAT APPLY TO PREVENTIVE SERVICES:

1. Recementation of a space maintainer within six months of initial placement is not a covered benefit.

EXCLUSIONS THAT APPLY TO RESTORATIVE SERVICES:

1. Fillings are not a covered benefit when crowns are allowed for the same teeth.
2. Replacement of any existing cast restoration (crowns, onlays, ceramic restorations) with any type of cast restoration within 84 months following initial placement of existing restoration is not a covered benefit.
3. Replacement of a stainless-steel crown with any type of cast restoration is not a covered benefit by the same office within 24 months following initial placement.
4. A cast restoration is a covered benefit only in the presence of radiographic evidence of decay or missing tooth structure. Restorations placed for any other purpose, including, but not limited to, cosmetics, abrasion, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformations of teeth, or the anticipation of future fractures, are not a covered benefit.
5. When there is radiographic evidence of sufficient vertical height (more than three millimeters above the crestal bone) on a tooth to support a cast restoration, a crown build-up is not a covered benefit.
6. The repair of any component of a cast restoration is not a covered benefit.
7. Recementation of inlays, onlays, partial coverage restorations, cast and prefabricated posts and cores and crowns by the same office within six months of initial placement is not a covered benefit.
8. Additional procedures to construct a new crown under the existing partial denture framework within six months following initial placement is not a covered benefit.
9. When a sedative filling is requested or placed on the same date as a permanent filling, the sedative filling is not a covered benefit.
10. Major restoratives for a patient under age 12 is not a covered benefit.

EXCLUSIONS THAT APPLY TO ENDODONTIC SERVICES:

1. When a benefit has been issued for endodontic services, retreatment of the same tooth within two years is not a covered benefit.
2. Endodontic procedures performed in conjunction with complete removable prosthodontic appliances are not a covered benefit.

EXCLUSIONS THAT APPLY TO PERIODONTIC SERVICES:

1. Guided tissue regeneration billed in conjunction with implantology, ridge augmentation/sinus lift, extractions or Periradicular surgery/apicoectomy is not a covered benefit.
2. Crown lengthening or gingivoplasty, if not performed at least four weeks prior to crown preparation, is not a covered benefit.
3. Bone replacement grafts performed in conjunction with extractions or implants are not a covered benefit.
4. Periodontal splinting to restore occlusion is not a covered benefit.

EXCLUSIONS THAT APPLY TO PROSTHODONTIC SERVICES:

1. Replacement of any existing prosthodontic appliance (cast restorations, fixed partial dentures, removable partial dentures, complete denture) with any prosthodontic appliance within 84 months following initial placement of existing appliance is not a covered benefit.
2. When a fixed partial denture and a removable partial denture are requested or placed in the same arch, the fixed partial denture is not a covered benefit.
3. Any prosthodontic appliance connected to an implant is not a covered benefit.
4. Reline or rebase of an existing appliance within six months following initial placement is not a covered benefit.
5. Fixed or removable prosthodontics for a patient under age 16 is not a covered benefit.
6. When the edentulous (toothless) space between teeth is less than 50% of the size of the missing tooth, a pontic is not a covered benefit.

EXCLUSIONS THAT APPLY TO ORAL SURGERY:

1. Mobilization of an erupted or malpositioned tooth to aid eruption or placement of a device to facilitate eruption of an impacted tooth performed in conjunction with other oral surgery is not a covered benefit.

GENERAL EXCLUSIONS THAT APPLY TO ALL PROCEDURES:

Coverage is NOT provided for:

1. Services compensable under Worker’s Compensation or Employer’s Liability laws.
2. Services provided or paid for by any governmental agency or under any governmental program or law, except as to charges which the person is legally obligated to pay. This exception extends to any benefits provided under the U.S. Social Security Act and its Amendments.
3. Services performed to correct developmental malformation including, but not limited to, cleft palate, mandibular prognathism, enamel hypoplasia, fluorosis and congenitally missing teeth. This exclusion does not apply to newborn infants.
4. Services performed for purely cosmetic purposes, including, but not limited to, tooth-colored veneers, bonding, porcelain restorations and microabrasion. Orthodontic care benefits shall fall within this exclusion unless such benefits are provided by endorsement.
5. Charges for services completed prior to the date the person became covered under this program.
6. Services for anesthetists or anesthesiologists.
7. Temporary procedures.
8. Any procedure requested or performed on a tooth when radiographs indicate that less than 40% of the root is supported by bone.
9. Services performed on non-functional teeth (second or third molar without an opposing tooth).
10. Services performed on deciduous (primary) teeth near exfoliation.
11. Drugs or the administration of drugs, except for general anesthesia and intravenous conscious sedation.
12. Procedures deemed experimental or investigational by the American Dental Association, for which there is no procedure code, or which are inconsistent with Current Dental Terminology coding and nomenclature.
13. Services with respect to any disturbance of the temporomandibular joint (jaw joint).
14. Procedures, techniques or materials related to implantology or edentulous (toothless) ridge enhancement.
15. Procedures that Delta Dental considers to be included in the fees for other procedures. For such procedures, a separate payment will not be made by this group dental plan. A Dentist in the Delta Dental PPO or Delta Dental Premier network may not bill the patient for such procedures.
16. The completion of claim forms and submission of required information, not otherwise covered, for determination of benefits.
17. Infection control procedures and fees associated with compliance with Occupational Safety and Health Administration (OSHA) requirements.
18. Broken appointments.
19. Services and supplies for any illness or injury occurring on or after the covered individual’s effective date of coverage as a result of war or an act of war.
20. Services for, or in connection with, an intentional self-inflicted injury or illness while sane or insane, except when due to domestic violence or a medical (including both physical and mental) health condition.
21. Services and supplies received from either a covered individual’s or covered individual’s spouse’s relative, any individual who ordinarily resides in the covered individual’s home or any such similar person.
22. Services for, or in connection with, an injury or illness arising out of the participation in, or in consequence of having participated in, a riot, insurrection or civil disturbance or the commission of a felony.
23. Charges for services for inpatient/outpatient hospitalization.
24. Services or supplies for oral hygiene or plaque control programs.
25. Services or supplies to correct harmful habits.