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Blue Cross Blue Shield FEP Dental Brochure - 2023

 
 
 
Blue Cross Blue Shield FEP Dental
Section 7 General Exclusions - Things We Do Not Cover
 
Section 7 General Exclusions – Things We Do Not Cover
 
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition.

We do not cover the following:
 
  • Services and treatment 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, we 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;
     
  • Services and treatment which are experimental or investigational;
     
  • Services and treatment 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 you claim the benefits or compensation;
     
  • Services and treatment 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;
     
  • Services and treatment performed prior to your effective date of coverage;
     
  • Services and treatment incurred after the termination date of your coverage unless otherwise indicated;
     
  • Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice.
     
  • Services and treatment resulting from your failure to comply with professionally prescribed treatment;
     
  • Any charges for failure to keep a scheduled appointment;
     
  • Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
     
  • Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD);
     
  • Services or treatment provided as a result of intentionally self-inflicted injury or illness;
     
  • 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;
     
  • Office infection control charges;
     
  • Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
     
  • State or territorial taxes on dental services performed;
     
  • Those services submitted by a dentist, which is for the same services performed on the same date for the same member by another dentist;
     
  • Those services provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
     
  • Those services for which the member would have no obligation to pay in the absence of this or any similar coverage;
     
  • Those services which are for specialized procedures and techniques;
     
  • Those services performed by a dentist who is compensated by a facility for similar covered services performed for members;
     
  • Duplicate, provisional and temporary devices, appliances, and services;
     
  • Plaque control programs, oral hygiene instruction, and dietary instructions;
     
  • 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;
     
  • Gold foil restorations;
     
  • Charges for sterilizing;
     
  • 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;
     
  • 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;
     
  • Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient);
     
  • Charges by the provider for completing dental forms;
     
  • Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it;
     
  • Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners;
     
  • Cone Beam Imaging and Cone Beam MRI procedures;
     
  • Sealants for teeth other than permanent molars are not covered. Initial placement of sealants are covered on unrestored 1st molars between ages of 6 through 9 and for 2nd permanent molars between ages 12 through 15. Repair /replacement are covered up to age 22 once every 24 months;
     
  • Precision attachments, personalization, precious metal bases and other specialized techniques;
     
  • Replacement of dentures that have been lost, stolen or misplaced;
     
  • Repair of damaged orthodontic appliances;
     
  • Replacement of lost or missing appliances;
     
  • External bleaching;
     
  • Nitrous oxide;
     
  • Oral sedation;
     
  • Topical medicament center;
     
  • Bone grafts when done in connection with extractions, apicoetomies or non-covered/non-eligible implants;
     
  • Interim therapeutic restoration - primary;
     
  • Veneers;
     
  • Blood glucose level test - in-office using a glucose meter;
     
  • Temporomandibular joint dysfunction – non-invasive physical therapies; and
     
  • Duplicate/copy patient's records
     
  • When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other service) as determined by BCBS FEP Dental.
     
  • 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), the Plan will pay for the service that represents the final treatment as determined by this plan.
     
  • Incomplete Endodontic Therapy, inoperable, unrestorable or fractured tooth is not a covered service.
 

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