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5.2.3 Endodontic Retreatment. <br />a. When the initial root canal therapy was performed by the Participating Provider, the <br />retreatment of the root canal therapy will be covered as part of the initial treatment for <br />the first 24 months. After 24 months, the applicable Copayments will apply. <br />b. When the initial root canal therapy was performed by a Non -Participating Provider, the <br />retreatment of such root canal therapy by the Participating Provider will be subject to <br />the applicable Copayments. <br />5.2.4 General Anesthesia. General anesthesia is covered with the Copayments specified in <br />Appendix A only if the following criteria are met: <br />a It is performed in a dental office; <br />b It is provided in conjunction with a Covered Service; and <br />c. The Participating Provider determines that it is necessary because the Enrollee is <br />under age 7, developmentally disabled, or physically handicapped. <br />5.2.5 Hospital Setting. The services provided by a Dentist in a hospital setting are covered if <br />the following criteria are met <br />a. A hospital or similar setting is medically necessary; <br />b. The services are authorized in writing by the Participating Provider; <br />c. The services provided are the same services that would be provided in a dental office; <br />and <br />d. The applicable Copayments are paid. <br />5.2.6 Replacements. The replacement of an existing denture, crown, inlay, onlay, or other <br />prosthetic appliance is covered if the appliance is more than 5 years old and replacement <br />is dentally necessary due to one of the following conditions: <br />a. A tooth within an existing denture or bridge is extracted; <br />b. The existing denture, crown, inlay, onlay or other prosthetic appliance or restoration <br />cannot be made serviceable; or <br />c. The existing denture was an immediate denture to replace one or more natural teeth <br />extracted while covered under this Contract, and replacement by a permanent denture <br />is necessary. <br />5.2.7 Restorations. Crowns, casts, or other indirect fabricated restorations are covered only if <br />dentally necessary and if recommended by the Participating Provider. Crowns, casts, or <br />other indirect fabricated restorations are dentally necessary if provided for treatment for <br />decay, traumatic injury, or substantial Toss of tooth structure undermining one or more <br />cusps and the tooth cannot be restored with a direct restorative material or the tooth is an <br />abutment to a covered partial denture or fixed bridge. <br />001 L-WA811(5/20) 15 <br />