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These Are The Exclusions For The Delta Dental Veterans Insurance Plans

(These Plans Are Dental Insurance And PPO's)

Delta Dental Veterans Plan Exclusions

1. Any dental service or treatment not specifically listed as a covered service.
2. Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist.  In these states, Delta Dental will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law.
3. Services or treatment provided by a member of your immediate family or a member of the immediate family of your spouse.
4. Those submitted by a dentist which is for the same services performed on the same date for the same member by another dentist.
5. Those which are experimental or investigative (deemed unproven).
6. Those which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit.  This exclusion applies whether or not the member claims the benefits or compensation.
   Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
   
   
7. Those which are later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law.
8. Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law.
9. Those for which the member would have no obligation to pay in the absence of this or any similar coverage.
10. Those received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.
11. Those performed prior to the member’s effective coverage date.
12. Those incurred after the termination date of the member’s coverage unless otherwise indicated.
13. Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist.  (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the patient by a participating dentist unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment.  Participating dentists should document such notification in their records.)
14. Those not meeting accepted standards of dental practice.
15. Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association.
16. Those performed by a dentist who is compensated by a facility for similar covered services performed for members.
17. Those resulting from the patient’s failure to comply with professionally prescribed treatment.
18. Telephone consultations.
19. Any charges for failure to keep a scheduled appointment.
20. Duplicate and temporary devices, appliances, and services.
21. Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMJD).
22. Plaque control programs, oral hygiene instruction, and dietary instructions.
23. Services to alter vertical dimension and/or restore or maintain the occlusion.  Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.
24. Gold foil restorations.
25. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan.
26. Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization.
27. Services or treatment provided as a result of intentionally self-inflicted injury or illness.
28. Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection.
29. Office infection control charges.
30. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient).
31. Adjunctive dental services as defined by applicable federal regulations.
32. Charges for copies of members’ records, charts or x-rays, or any costs associated with forwarding/mailing copies of members’ records, charts or x-rays.
33. Nitrous oxide.
34. Oral sedation.
35. State or territorial taxes on dental services performed.

Delta Dental Veterans Standard Plan Limits

1. Two oral evaluations (D0120, D0150 and D0180) are covered in a 12 consecutive month period.  A comprehensive periodontal evaluation will be considered integral if provided on the same date of service by the same dentist as any other oral evaluation.
2. Only one (1) comprehensive evaluation (D0150) will be allowed in a 12 consecutive month period.
3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a 12 consecutive month period.  A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.
4. Re-evaluations are considered integral to the originally performed procedures.
5. Payment for more than one of any category of full-mouth radiographs within a 48-month period is the patient’s responsibility.  If a full-mouth series (complete series) is denied because of the 48-month limitation, it cannot be reprocessed and paid as bitewings and/or additional films.
6. A panoramic radiograph taken with any other radiographic image is considered a full-mouth series and is paid as such, and is subject to the same benefit limitation.  Payment for panoramic radiographs is limited to one within a 48-month period.

1. Two routine prophylaxes are covered in a 12 consecutive month period.
2. Routine prophylaxis includes associated scaling and polishing procedures.  There are no provisions for any additional allowance based on degree of difficulty.
3. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such.  Participating dentists may not bill the patient for any difference in fees.
4. Two topical fluoride applications are covered in a 12 consecutive month period.
5. Space maintainers are only covered for dependent children under the age of 19.
6. Sealants are covered on permanent molars through age 18.  The teeth must be caries-free with no previous restorations on the mesial, distal or occlusal surfaces.  One sealant per tooth is covered in a three year period.
7. Sealants for teeth other than permanent molars are not covered.
8. Sealants provided on the same date of service and on the same tooth as a restoration of the occlusal surface are considered integral procedures.

1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.
2. Sedative restorations are not a covered benefit.
3. Pin retention is covered only when reported in conjunction with an eligible restoration.
4. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin buildup (D2950).
5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.
6. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 24 months of the original restoration are considered integral procedures, and a separate fee is not chargeable to the member by a participating dentist.  However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.
7. Restorations are not covered when performed after the placement of any type of crown or onlay, on the same tooth and by the same dentist.
8. The payment for restorations includes all related services to include, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents.
9. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury.  They are limited to one per patient, per tooth, per lifetime.
10. The charge for a crown should include all charges for work related to its placement to include, but not limited to, preparation of gingival tissue, tooth preparation, diagnostic casts (study models), impressions, try-in visits, and cementation of a permanent crown.
11. Crowns are payable only when necessary due to decay or tooth fracture.  However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, payment will be made for that service.  This payment can be applied toward the cost of the crown.
12. Recementation of prefabricated and cast crowns, onlays, inlays, is eligible once per six month period.  Recementation provided within 12 months of placement by the same dentist is considered integral.
13. Payment for a resin restoration will be made when a laboratory fabricated porcelain or resin veneer is used to restore any teeth due to tooth fracture or caries.

1. Routine postoperative care such as suture removal is considered integral to the fee for the oral surgery services.

Delta Dental Veterans Enhanced Plan Limits

1. Two oral evaluations (D0120, D0150 and D0180) are covered in a 12 consecutive month period.  A comprehensive periodontal evaluation will be considered integral if provided on the same date of service by the same dentist as any other oral evaluation.
2. Only one (1) comprehensive evaluation (D0150) will be allowed in a 12 consecutive month period.
3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a 12 consecutive month period.  A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.
4. Re-evaluations are considered integral to the originally performed procedures.
5. Payment for more than one of any category of full-mouth radiographs within a 48-month period is the patient’s responsibility.  If a full-mouth series (complete series) is denied because of the 48-month limitation, it cannot be reprocessed and paid as bitewings and/or additional films.
6. A panoramic radiograph taken with any other radiographic image is considered a full-mouth series and is paid as such, and is subject to the same benefit limitation.  Payment for panoramic radiographs is limited to one within a 48-month period.

1. Two routine prophylaxes are covered in a 12 consecutive month period.
2. Routine prophylaxes are considered integral when performed by the same dentist on the same day as scaling and root planing, periodontal surgery and periodontal maintenance procedures.
3. Routine prophylaxes are considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomies or gingivoplasties, gingival flap procedures, mucogingival surgery, or osseous surgery.
4. Routine prophylaxis includes associated scaling and polishing procedures.  There are no provisions for any additional allowance based on degree of difficulty.
5. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such.  Participating dentists may not bill the patient for any difference in fees.
6. Two topical fluoride applications are covered in a 12 consecutive month period.
7. Space maintainers are only covered for dependent children under the age of 19.
8. Sealants are covered on permanent molars through age 18.  The teeth must be caries- free with no previous restorations on the mesial, distal or occlusal surfaces.  One sealant per tooth is covered in a three year period.
9. Sealants for teeth other than permanent molars are not covered.
10. Sealants provided on the same date of service and on the same tooth as a restoration of the occlusal surface are considered integral procedures.

1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.
2. Sedative restorations are not a covered benefit.
3. Pin retention is covered only when reported in conjunction with an eligible restoration.
4. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin buildup (D2950).
5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.
6. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 24 months of the original restoration are considered integral procedures, and a separate fee is not chargeable to the member by a participating dentist.  However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.
7. Restorations are not covered when performed after the placement of any type of crown on the same tooth and by the same dentist.
8. The payment for restorations includes all related services to include, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents.
9. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury.  They are limited to one per patient, per tooth, per lifetime.
10. The charge for a crown should include all charges for work related to its placement to include, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, and cementations of both temporary and permanent crowns.
11. Crowns are payable only when necessary due to decay or tooth fracture.  However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, payment will be made for that service.  This payment can be applied toward the cost of the crown.
12. Recementation of prefabricated and cast crowns, onlays, and inlays is eligible once per six month period.  Recementation provided within 12 months of placement by the same dentist is considered integral.
13. Payment for a resin restoration will be made when a laboratory fabricated porcelain or resin veneer is used to restore any teeth due to tooth fracture or caries.

1. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy.
2. A pulpotomy is covered when performed as a final endodontic procedure and is payable on primary teeth only.  Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth.
3. Pulpal therapy (resorbable filling) is limited to primary teeth only.  It is a benefit for primary incisor teeth for members up to age six and for primary molars and cuspids to age 11 and is limited to once per tooth per lifetime.  Payment for the pulpal therapy will be offset by the allowance for a pulpotomy provided within 45 days preceding pulpal therapy on the same tooth by the same dentist.
4. Treatment of a root canal obstruction is considered an integral procedure.
5. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment.
6. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.
7. Placement of a final restoration following endodontic therapy is a separate procedure, payable based on plan coverage.

1. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone replacement grafts and osseous surgery provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth are not covered.
2. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, posts and cores or basic restorations are considered integral to the restoration.
3. Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival flap procedure are not covered.
4. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the same area of the mouth as periodontal surgical procedures, endodontic procedures and oral surgery procedures.
5. Subepithelial connective tissue grafts and combined connective tissue and double pedicle grafts are payable at the level of free soft tissue grafts.  The difference between the allowance for the soft tissue graft and the dentist’s charge is the patient’s responsibility.
6. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved.  Another site on the same tooth is considered integral to the first site reported.  Non-contiguous areas involving different teeth may be reported as additional sites.
7. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth.
8. Osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service, by the same dentist, and in the same area of the mouth, will be processed as crown lengthening.
9. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or interbony defects.  It is not covered when provided to obtain root coverage, or when provided in conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g., apicoectomy or hemisection.
10. One crown lengthening per tooth, per lifetime, is covered.
11. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal surgical procedures, in the same area of the mouth is not covered.
12. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty, gingival flap procedure or osseous surgery.
13. Up to four periodontal maintenance procedures and up to two routine prophylaxes may be paid within a 12-consecutive month period, but the total of periodontal maintenance and routine prophylaxes may not exceed four procedures in a 12-month period.
14. Periodontal maintenance is only covered when performed following active periodontal treatment.
15. An oral evaluation reported in addition to periodontal maintenance will be processed as a separate procedure subject to the policy and limitations applicable to oral evaluations.
16. Payment for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and guided tissue regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater surgical procedure.  The lesser procedure is considered integral and its allowance is included in the allowance for the greater procedure.
17. Surgical revision procedure (D4268) is considered integral to all other periodontal procedures.
18. Full mouth debridement to enable comprehensive evaluation and diagnosis (code D4355) is covered once per lifetime.

1. Routine postoperative care such as suture removal is considered integral to the fee for the oral surgery services.

Delta Dental Veterans Comprehensive Plan Limits

1. Two oral evaluations (D0120, D0150 and D0180) are covered in a 12 consecutive month period.  A comprehensive periodontal evaluation will be considered integral if provided on the same date of service by the same dentist as any other oral evaluation.
2. Only one (1) comprehensive evaluation (D0150) will be allowed in a 12 consecutive month period.
3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a 12 consecutive month period.  A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.
4. Re-evaluations are considered integral to the originally performed procedures.
5. Payment for more than one of any category of full-mouth radiographs within a 48-month period is the patient’s responsibility.  If a full-mouth series (complete series) is denied because of the 48-month limitation, it cannot be reprocessed and paid as bitewings and/or additional films.
6. A panoramic radiograph taken with any other radiographic image is considered a full-mouth series and is paid as such, and is subject to the same benefit limitation.  Payment for panoramic radiographs is limited to one within a 48-month period.

1. Two routine prophylaxes are covered in a 12 consecutive month period.
2. Routine prophylaxes are considered integral when performed by the same dentist on the same day as scaling and root planing, periodontal surgery and periodontal maintenance procedures.
3. Routine prophylaxes are considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomies or gingivoplasties, gingival flap procedures, mucogingival surgery, or osseous surgery.
4. Routine prophylaxis includes associated scaling and polishing procedures.  There are no provisions for any additional allowance based on degree of difficulty.
5. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such.  Participating dentists may not bill the patient for any difference in fees.
6. Two topical fluoride applications are covered in a 12 consecutive month period.
7. Space maintainers are only covered for dependent children under the age of 19.
8. Sealants are covered on permanent molars through age 18.  The teeth must be caries-free with no previous restorations on the mesial, distal or occlusal surfaces.  One sealant per tooth is covered in a six year period.
9. Sealants for teeth other than permanent molars are not covered.
10. Sealants provided on the same date of service and on the same tooth as a restoration of the occlusal surface are considered integral procedures.

1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.
2. Sedative restorations are not a covered benefit.
3. Pin retention is covered only when reported in conjunction with an eligible restoration.
4. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin buildup (D2950).
5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.
6. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 24 months of the original restoration are considered integral procedures, and a separate fee is not chargeable to the member by a participating dentist.  However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.
7. Restorations are not covered when performed after the placement of any type of crown or onlay, on the same tooth and by the same dentist.
8. The payment for restorations includes all related services to include, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents.
9. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury.  They are limited to one per patient, per tooth, per lifetime.
10. The charge for a crown or onlay should include all charges for work related to its placement to include, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, and cementations of both temporary and permanent crowns.
11. Onlays, permanent single crown restorations, and posts and cores for members 12 years of age or younger are excluded from coverage, unless specific rationale is provided indicating the reason for such treatment (e.g., fracture, endodontic therapy, etc.).
12. Core buildups (D2950) can be considered for benefits only when there is insufficient retention for a crown.  A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities in the preparation.
13. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core.  The patient is responsible for the difference between the dentist’s charge for the cast post and core and the amount paid for the prefabricated post and core.
14. Replacement of crowns, onlays, buildups, and posts and cores is covered only if the existing crown, onlay, buildup, or post and core was inserted at least five years prior to the replacement.  Satisfactory evidence must show that the existing crown, onlay, buildup, or post and core is not and cannot be made serviceable.  The five year service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month.
15. Onlays, crowns, and posts and cores are payable only when necessary due to decay or tooth fracture.  However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, payment will be made for that service.  This payment can be applied toward the cost of the onlay, crown, or post and core.
16. Crowns, inlays, onlays, buildups, or posts and cores, begun prior to the effective date of coverage or cemented after the cancellation date of coverage, are not eligible for payment.
17. Recementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per six month period.  Recementation provided within 12 months of placement by the same dentist is considered integral.
18. When performed as an independent procedure, the placement of a post is not a covered benefit.  Posts are only eligible when provided as part of a buildup for a crown or implant and are considered integral to the buildup or implant.
19. Payment for a resin restoration will be made when a laboratory fabricated porcelain or resin veneer is used to restore any teeth due to tooth fracture or caries.

1. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy.
2. A pulpotomy is covered when performed as a final endodontic procedure and is payable on primary teeth only.  Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth.
3. Pulpal therapy (resorbable filling) is limited to primary teeth only.  It is a benefit for primary incisor teeth for members up to age six and for primary molars and cuspids to age 11 and is limited to once per tooth per lifetime.  Payment for the pulpal therapy will be offset by the allowance for a pulpotomy provided within 45 days preceding pulpal therapy on the same tooth by the same dentist.
4. Treatment of a root canal obstruction is considered an integral procedure.
5. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment.
6. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.
7. Placement of a final restoration following endodontic therapy is a separate procedure, payable based on plan coverage.

1. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone replacement grafts and osseous surgery provided within 24 months of the same surgical periodontal procedure, in the same area of the mouth are not covered.
2. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, posts and cores or basic restorations are considered integral to the restoration.
3. Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival flap procedure are not covered.
4. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the same area of the mouth as periodontal surgical procedures, endodontic procedures and oral surgery procedures.
5. Subepithelial connective tissue grafts and combined connective tissue and double pedicle grafts are payable at the level of free soft tissue grafts.  The difference between the allowance for the soft tissue graft and the dentist’s charge is the patient’s responsibility.
6. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved.  Another site on the same tooth is considered integral to the first site reported.  Non-contiguous areas involving different teeth may be reported as additional sites.
7. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth.
8. Osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service, by the same dentist, and in the same area of the mouth, will be processed as crown lengthening.
9. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or interbony defects.  It is not covered when provided to obtain root coverage, or when provided in conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g., apicoectomy or hemisection.
10. One crown lengthening per tooth, per lifetime, is covered.
11. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal surgical procedures, in the same area of the mouth is not covered.
12. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty, gingival flap procedure or osseous surgery.
13. Up to four periodontal maintenance procedures and up to two routine prophylaxes may be paid within a 12-consecutive month period, but the total of periodontal maintenance and routine prophylaxes may not exceed four procedures in a 12-month period.
14. Periodontal maintenance is only covered when performed following active periodontal treatment.
15. An oral evaluation reported in addition to periodontal maintenance will be processed as a separate procedure subject to the policy and limitations applicable to oral evaluations.
16. Payment for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and guided tissue regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater surgical procedure.  The lesser procedure is considered integral and its allowance is included in the allowance for the greater procedure.
17. Surgical revision procedure (D4268) is considered integral to all other periodontal procedures.
18. Full mouth debridement to enable comprehensive evaluation and diagnosis (code D4355) is covered once per lifetime.

1. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to Effective Date of Coverage may not be eligible for coverage.
   
   Unless you have a tooth extracted while insured by this company, there is no benefit for any prosthetic appliance (dentures or partials) or fixed partial denture (bridges).
   
   
2. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date.  The completion date is the insertion date for removable prosthodontic appliances.  For immediate dentures, however, the provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an oral surgeon, inserted the dentures.
3. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures are included in the fee for these procedures.  A separate fee is not chargeable to the member by a participating dentist.
4. Tissue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/rebase.
5. Recementation of crowns, fixed partial dentures, inlays, onlays, or cast posts within six months of their placement by the same dentist is considered integral to the original procedure.
6. Adjustments provided within six months of the insertion of an initial or replacement denture or implant are integral to the denture or implant.
7. The relining or rebasing of a denture is considered integral when performed within six months following the insertion of that denture.
8. A reline/rebase is covered once in any 36 months.
9. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are not covered unless specific rationale is provided indicating the necessity for such treatment.
10. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture.  Specialized procedures performed in conjunction with an overdenture are not covered.  Any additional cost is the member’s responsibility.
11. A fixed partial denture and removable partial denture are not covered benefits in the same arch.  Payment will be made for a removable partial denture to replace all missing teeth in the arch.
12. Cast unilateral removable partial dentures are not covered benefits.
13. Precision attachments, personalization, precious metal bases, and other specialized techniques are not covered benefits.
14. Temporary fixed partial dentures are not a covered benefit and, when done in conjunction with permanent fixed partial dentures, are considered integral to the allowance for the fixed partial dentures.
15. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a three unit fixed partial denture.
16. Replacement of removable prostheses (D5110 through D5214) and fixed prostheses (D6210 through D6792) is covered only if the existing removable and/or fixed prostheses was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing removable and/or fixed prostheses cannot be made serviceable.  Satisfactory evidence must show that the existing removable prostheses and/or fixed prostheses cannot be made serviceable.  The five-year service date is measured based on the actual date (day and month) of the initial service versus the first day of the initial service month.
17. Replacement of dentures that have been lost, stolen, or misplaced is not a covered service.
18. Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the cancellation date of coverage are not eligible for payment.

1. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy.
2. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess.  Routine follow up care is considered integral to the procedure.
3. Charges for related services such as necessary wires and splints, adjustments, and follow up visits are considered integral to the fee for reimplantation and/or stabilization.
4. Routine postoperative care such as suture removal is considered integral to the fee for the oral surgery services.
5. The removal of impacted teeth is paid based on the anatomical position as determined from a review of x-rays.  If the degree of impaction is determined to be less than the reported degree, payment will be based on the allowance for the lesser level.
6. Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless specific documentation is provided that substantiates the need for removal.

1. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) and when rendered by a dentist or other professional provider licensed and approved to provide anesthesia in the state where the service is rendered.
2. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions.
3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which it was provided must be submitted and approved.
4. Deep sedation/general anesthesia and intravenous conscious sedation submitted without a report will be denied as a non-covered benefit.
5. For palliative (emergency) treatment to be covered; it must involve a problem or symptom that occurred suddenly and unexpectedly that requires immediate attention.
6. In order for palliative (emergency) treatment to be covered, the dentist must provide treatment to alleviate the member’s problem.  If the only service provided is to evaluate the patient and refer to another dentist and/or prescribe medication, it would be considered a limited oral evaluation - problem focused.
7. Consultations are covered only when provided by a dentist other than the practitioner providing the treatment.
8. Consultations reported for a non-covered benefit, such as temporomandibular joint dysfunction (TMJD), are not covered.
9. After hours visits are covered only when the dentist must return to the office after regularly scheduled hours to treat the patient in an emergency situation.
10. Therapeutic drug injections are only payable in unusual circumstances, which must be documented by report.  They are not benefits if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication.
11. Preparations that can be used at home, such as fluoride gels, special mouth rinses (including antimicrobials), etc., are not covered benefits.
12. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD).  Occlusal guards are limited to one per 12 consecutive month period.
13. Athletic mouth guards are limited to one per 12 consecutive month period.
14. Internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior teeth.  A postoperative endodontic x-ray is required for consideration if the endodontic therapy has not been submitted to Delta Dental for payment.
15. Internal bleaching of discolored teeth (D9974) is eligible once per tooth per three year period.

Delta Dental Enhanced & Classic Plan Exclusions

1. Cosmetic services or supplies, including cosmetic work done on dentures.
2. Any procedures done to restore the height and/or width of teeth.
3. General anesthesia and/or intravenous (deep) sedation, except when this policy says otherwise.
4. Braces and retainers (orthodontia), and services related to braces and retainers.
   This is especially important for anyone in need of braces.
   
   
5. Oral surgery, including surgical extractions.
6. Preventive control programs.
7. Injuries or conditions covered under Workers’ Compensation or Employer's Liability laws; services provided by any government agency; or any services that are provided free exceptas pursuant to Title XIX of the Social Security Act.
   Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
   
   
8. Treatments that are still under investigation or observation.
9. Prescription drugs.
10. Pain relievers like nitrous oxide, conscious sedation, euphoric drugs, or injections.
11. Hospitalization charges and related charges.
12. Consultations or second opinions.
13. Charges for missed appointments.
14. Patient management problems.
15. Charges for completing claim forms.
16. Habit-breaking appliances.
17. Temporomandibular joint (TMJ) services or supplies.
18. Brushing and flossing instructions, tobacco and nutritional counseling.
19. Any dental services provided to anyone covered under this policy while they are on active service in the Armed Forces.
20. Any dental services to treat injuries or diseases caused by any form of civil disobedience or criminal act, or any injuries intentionally inflicted.
21. Any dental services performed or started before this policy took effect.
22. Any dental services performed or started after this policy ends.
23. Laboratory tests and/or laboratory examinations.
24. Procedures provided by someone other than a dentist or licensed hygienist employed by a dentist.
25. Anything determined (by Delta Dental) not to be necessary for treating a dental condition, disease or injury.
26. Replacement of a lost, missing or stolen denture or bridge.
27. Duplicate dentures or bridges, or any other duplicate appliance.
28. Repair or replacement of orthodontic appliances.
29. Free services or supplies.
30. Services covered or provided under any other plan or policy.
31. Claims not submitted within 15 months of the date of service.
32. Any other service not specifically listed in this policy as a benefit.

Delta Dental Basic Plan Exclusions

1. Cosmetic services or supplies, including cosmetic work done on dentures.
2. Any procedures done to restore the height and/or width of teeth.
3. General anesthesia and/or intravenous (deep) sedation, except when this policy says otherwise.
4. Braces and retainers (orthodontia), and services related to braces and retainers..
   This is especially important for anyone in need of braces.
   
   
5. Oral surgery, including surgical extractions.
6. Endodontics.
7. Periodontics, including Periodontal maintenance.
8. Major restorative services including crowns, bridges, partial and complete dentures and implants.
9. Preventive control programs.
10. Injuries or conditions covered under Workers’ Compensation or Employer's Liability laws; services provided by any government agency; or any services that are provided free except as pursuant to Title XIX of the Social Security Act.
    Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
    
    
11. Treatments that are still under investigation or observation.
12. Prescription drugs.
13. Pain relievers like nitrous oxide, conscious sedation, euphoric drugs, or injections.
14. Hospitalization charges and related charges.
15. Consultations or second opinions.
16. Charges for missed appointments.
17. Patient management problems.
18. Charges for completing claim forms.
19. Habit-breaking appliances.
20. Temporomandibular joint (TMJ) services or supplies.
21. Brushing and flossing instructions, tobacco and nutritional counseling.
22. Any dental services provided to anyone covered under this policy while they are on active service in the Armed Forces.
23. Any dental services to treat injuries or diseases caused by any form of civil disobedience or criminal act, or any injuries intentionally inflicted.
24. Any dental services performed or started before this policy took effect.
25. Any dental services performed or started after this policy ends.
26. Laboratory tests and/or laboratory examinations.
27. Procedures provided by someone other than a dentist or licensed hygienist employed by a dentist.
28. Anything determined (by Delta Dental) not to be necessary for treating a dental condition, disease or injury.
29. Replacement of a lost, missing or stolen denture or bridge.
30. Duplicate dentures or bridges, or any other duplicate appliance.
31. Repair or replacement of orthodontic appliances.
32. Free services or supplies.
33. Services covered or provided under any other plan or policy.
34. Any other service not specifically listed in this policy as a benefit.
35. Claims not submitted within 15 months of the date of service.

Delta Dental Family Select & Family Essential Plan Exclusions

1. Any Dental Procedures, services, treatment or supplies provided or commenced prior to the effective date of the Covered Person’s coverage under the Policy or after the termination date of coverage unless otherwise indicated.
2. Charges for completion of forms.
3. Charges for consultation.
4. Gold foil restorations.
5. Dental Procedures, services, treatment and supplies not specifically covered under this Policy.
6. Prescription drugs, premedications or relative analgesia.
7. Charges for anesthesia other than charges by a Dentist for administering general anesthesia in connection with covered oral surgery (cutting procedures.)
8. Preventive control programs.
9. Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a Dentist for treatment in any such facility.
10. Charges for treatment of, or services related to, temporomandibular joint dysfunction.
11. Dental Procedures, services, treatment and supplies that are determined to be partially or wholly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances.
12. Cast restorations placed on Covered Persons under age 12.
13. Prosthetics placed on Covered Persons under age 16.
14. Dental Procedures, services, treatment and supplies which are experimental or investigational.
15. Dental Procedures, services, treatment and supplies which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit.  This exclusion applies whether or not the Covered Person claims the benefits or compensation.
    Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
    
    
16. Dental Procedures, services, treatment and supplies received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group.
17. Dental Procedures, services, treatment and supplies which are not dentally necessary or which do not meet generally accepted standards of dental practice.
18. Dental Procedures, services, treatment and supplies resulting from a Covered Person’s failure to comply with professionally prescribed treatment.
19. Any charges for failure to keep a scheduled appointment.
20. Office infection control charges.
21. Charges for copies of a Covered Person’s records, charts or x-rays, or any costs associated with forwarding/mailing copies of a Covered Person’s records, charts or x-rays.
22. Charges submitted by a Dentist which are for the same services performed on the same date for the same Covered Person by another Dentist.
23. Dental Procedures, services, treatment and supplies provided free of charge by any governmental unit, except as pursuant to Title XIX of the Social Security Act or where this exclusion is prohibited by law.
24. Dental Procedures, services, treatment and supplies for which the Covered Person would have no obligation to pay in the absence of this or any similar coverage.
25. Dental Procedures, services, treatment and supplies which are for specialized procedures and techniques for which there is not an associated Current Dental Terminology (CDT) Codeapproved by the American Dental Association.
26. Dental Procedures, services and treatment which are performed by a Dentist who is compensated by a facility for similar covered services performed for Covered Persons.
27. Plaque control programs, oral hygiene instruction and dietary instructions.
28. Dental Procedures, services, treatment and supplies for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under plan or policy of motor vehicle insurance, including a certified self-insurance plan.
29. Dental Procedures, services, treatment and supplies for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization.
30. Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it.
31. Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, and dental floss and teeth whiteners.
32. Cone Beam Imaging, MRI and ultrasound procedures.
33. Sealants for teeth other than permanent molars.
34. Precision attachments, personalization, precious metal bases and other specialized techniques.
35. Medically Necessary Orthodontic Services provided to a Covered Person who has not met the 24-month waiting period.
36. Medically Necessary Orthodontic Services if a predetermination of benefits has not been approved by Delta Dental.
37. Orthodontic Services except for Medically Necessary Orthodontic Services.
    This is especially important for anyone in need of braces.
    
    
38. Repair of damaged orthodontic appliances.
39. Replacement of lost or missing appliances.
40. Fabrication of athletic mouth guard.
41. Internal or external bleaching.
42. Nitrous oxide.
43. Topical medicament carrier.
44. Bone grafts when done in connection with extractions, apicoetomies or non-covered/non-eligible implants.
45. When two or more services are submitted and the services are considered part of the same service to one another, Delta Dental will pay the most comprehensive service (the servicethat includes the other non-benefited service) as determined by Delta Dental.
46. When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), Delta Dental will pay for the service that represents the final treatment as determined by Delta Dental.
47. Appliances, restorations, or procedures for:  
    • increasing vertical dimension;
    • restoring occlusion;
    • replacing tooth structure lost by attrition, erosion, abrasion, or abfraction.
    • correcting congenital or developmental malformations except in newly born or adopted children or children placed for adoption, or in conjunction with Medically Necessary Orthodontic Services;
    • replacement, provisional and temporary services, treatment or supplies;
    • splints, unless necessary as a result of accidental injury.
48. Dental Procedures, services, treatment and supplies provided by an individual other than a Dentist.
49. Dental Procedures, services, treatment and supplies to treat injuries or diseases caused by riots or any form of civil disobedience.
50. Dental Procedures, services, treatment and supplies to treat injuries sustained while committing a felony or engaging in an illegal occupation.
51. Dental Procedures, services, treatment and supplies to treat injuries intentionally inflicted.
52. Replacement of lost or stolen dentures or charges for duplicate dentures.
53. Dental Procedures, services, treatment and supplies in cases for which, in the professional judgment of the attending Dentist, a satisfactory result cannot be obtained.
54. Local anesthetic is covered as part of a Dental Procedure, service or treatment.  General anesthetic or intravenous sedation is a Benefit only when billed with covered oral surgery (cutting procedures).
55. Pre-diagnostic services, oral pathology laboratory procedures, and diagnostic tests and examinations other than pulp vitality tests.
56. Surgical removal of impacted third molars if a predetermination of benefits has not been approved by Delta Dental.
57. Dental Procedures, services, treatment or supplies for which benefit is provided by a medical or health plan.