Dental PPO

Benefit Exclusions

The following list, while not necessarily complete, gives examples of benefit exclusions:

• Services performed solely for cosmetic reasons
• Replacement of a lost or stolen appliance
• Replacement of a bridge or denture within five years following the date of its original installation
• Replacement of a bridge or denture which can be made usable according to dental standards
• Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion
• Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars
• Bite registrations; precision or semi-precision attachments; splinting
• Surgical implant of any type, including any prosthetic device attached to it
• Instruction for plaque control, oral hygiene and diet
• Dental services that do not meet common dental standards
• Services that are deemed to be medical services
• Services and supplies received from a hospital
• Charges which the person is not legally required to pay
• Experimental or investigational procedures and treatments
• Any injury resulting from, or in the course of, any employment for wage or profit
• Any sickness covered under any workers' compensation or similar law
• Charges in excess of the reasonable and customary allowances