BCBSNC Dental Bluesm Limitations and Exclusions


Dental Bluesm
Limitations and Exclusions

Dental Blue

Your dental benefit plan does not cover services, supplies, drugs, or charges that are:

• Not clinically necessary
• Hospitalization for any dental procedure
• Dental procedures performed solely for cosmetic or aesthetic reasons, except when dental procedures are performed in order to restore normal function to minor children with congenital defects and anomalies
• Dental procedure not directly associated with dental disease
• Procedures not performed in a dental setting
• Procedures that are considered to be experimental, including pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics
• Placement of dental implants, implant-supported abutments and prostheses. Implant sites will be considered edentulous areas for claims and processing purposes. This includes pharmacological regimens and restorative materials
• Drugs or medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit
• Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue
• Treatment of malignant or benign neoplasm's, cysts, or other pathology, except excision al removal. Treatment of congenital malformations of hard or soft tissue, excluding excision. Hard or soft tissue biopsies of neoplasm's, cysts, or soft tissue growths of unknown cellular make-up are not excluded
• Replacement of complete or partial dentures, fixed bridgework, or crowns within 60 months of initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances
• Services related to the temporomanidibular joint (TMJ), either bilateral or unilateral
• Expenses for dental procedures begin prior to the member’s eligibility with Blue Cross NC
• Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction
• Attachments to conventional removable prostheses or fixed bridgework, including semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial over dentures, any internal attachment associated with an implant prosthesis, and any elective endocentric procedure related to a tooth or root involved in the construction of a prosthesis of this nature
• Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO)
• Denture relines for complete or partial conventional dentures are not covered for six months following the insertion of a prosthesis. Tissue conditioning and soft and hard relines for immediate full and partial dentures are not covered for six months after insertion of the full or partial denture. After the six month waiting period, relines are covered once very 12 months.
• One hard tissue periodontal surgery and one soft tissue periodontal surgery per surgical area are covered within a three-year period. This includes gingivectomy, gingivoplasty, gingival curettage (with or without a flap procedure), osseous surgery, pedicel grafts, and free soft tissue grafts
• Osseous grafts, with or without resorbable or non-resorbable GTR membrane placement, are covered once every 36 months per quadrant or surgical site
• Clinical situations that can be effectively treated by a more cost-effective, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure
• Replacement of crowns, bridges and fixed or removable prosthetic appliances inserted prior to plan coverage until the patient has been eligible under this dental plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic and/or abutment(s) within this 12-month period, Blue Cross NC is responsible only for the procedures associated with the modification.
• Replacement of missing natural teeth lost prior to the effective date of coverage until the patient has been eligible for 12 continuous months. Replacement of teeth lost during the initial 12-month period of coverage is excluded until the patient has been eligible for 12 continuous months.
• Services for incision and drainage if the involved abscessed tooth is removed on the same date of service
• Full mouth debridement is limited to once every 36 months
• Occlusal guards for any purpose other than control of habitual grinding
• Placement of fixed bridgework solely for the purpose of achieving periodontal stability
• Orthodontic services