Laserfiche WebLink
5.1.14 Replacement of lost, missing, or stolen dental appliances. <br />5.1.15 Replacement of dental appliances that are damaged due to abuse, misuse, or neglect. <br />5.1.16 Replacement of sound restorations. <br />5.1.17 Services and related exams or consultations that are not within the prescribed treatment <br />plan and/or are not recommended and approved by the Participating Provider. <br />5.1.18 Services and related exams or consultations to the extent they are not necessary for the <br />diagnosis, care, or treatment of the condition involved. <br />5.1.19 Services by any person other than a Dentist, Dentunst, hygienist, or dental assistant within <br />the scope of his/her license. <br />5.1.20 Services for the treatment of an injury or disease that is covered under workers' <br />compensation or that are an employer's responsibility. <br />5.1.21 Services for the treatment of injuries sustained while practicing for or competing in a <br />professional athletic contest of any kind. <br />5.1.22 Services for the treatment of intentionally self-inflicted injuries. <br />5.1.23 Services for which coverage is available under any federal, state, or other governmental <br />program, unless required by law. <br />5.1.24 Services that are not listed as covered in the appendices. <br />5.1.25 Services where there is no evidence of pathology, dysfunction, or disease other than <br />covered preventive services. <br />5.2 Limitations. <br />5.2.1 Alternate Services. If alternative services can be used to treat a condition, the service <br />recommended by the Participating Provider is covered. In the event the Enrollee elects a <br />service that is more costly than the service the Participating Provider has approved, the <br />Enrollee is responsible for the Copayment for the recommended covered service plus the <br />cost differential between the Reasonable Cash Value of the recommended service and the <br />Reasonable Cash Value of the more costly requested service. <br />5.2.2 Congenital Malformations. Services listed in Appendix A which are provided to correct <br />congenital or developmental malformations which impair functions of the teeth and <br />supporting structures will be covered for Dependent Children if dental necessity has been <br />established. Dental necessity means that treatment is primarily for the purpose of <br />controlling or eliminating infection, controlling or eliminating pain, or restoring function <br />Orthognathic surgery is covered as specified in Appendix A if the Participating Provider <br />determines orthognathic surgery is dentally necessary and authorizes the orthognathic <br />surgery for treatment of an Enrollee who is under the age of 19 with congenital or <br />developmental malformations. <br />001 L-WA811(5/20) 14 <br />