2020/12/16 Council Agenda Packet

Appendix D - Dental Implants 1. Benefits. a. The dental implant services described in this Appendix D are covered for Enrollees if all of the following requirements are met: 1) A Participating Provider determines that dental implants are dentally appropriate for the Enrollee. 2) A Participating Provider prepares the treatment plan for dental implants prior to initiating any implant treatment. 3) All dental implant services are provided by a Participating Provider or under a referral from a Participating Provider. 4) The Enrollee follows the treatment plan prescribed by the Participating Provider. 5) The Enrollee makes payment of amounts due. 6) The dental implant service is listed as covered in this Appendix D and is not otherwise limited or excluded. Services After Termination of Benefits. If the Enrollee's coverage ends before the completion of the dental implant services the cost of any remaining treatment is the Enrollee's responsibility. c. Dental Implant Surgery. The following dental implant services are covered at 100% up to an annual dental implant benefit maximum of $1,500 per implant. The annual dental implant benefit maximum is the maximum dollar amount this Contract will cover for benefits for the below dental implant services in a calendar year. CDT Code and Procedure Description D6010 Surgical placement of implant body: endosteal implant D6011 Second stage implant surgery 2. Limitations. The benefit for dental implants is subject to the following limitations: a. Benefits for surgical placement of a dental implant is limited to 1 per calendar year b. Dental implants to replace an existing bridge or existing denture will not be covered, unless 5 years have elapsed since the placement of the bridge or delivery of the denture. 3. Exclusions. The following services are not covered under this benefit for dental implants: a. Any dental implant services and related services that are not listed as covered on this Appendix D. b. Bone grafting. c. Cone beam CT X-rays and tomographic surveys. d. Dental implant -supported prosthetics or abutment -supported prosthetics (crowns, bridges, and dentures). e. A dental implant that was surgically placed prior to the Enrollee's effective date of coverage under this Contract and has not received final restoration. f. Eposteal, transosteal, endodontic endosseous, or mini dental implants. Maintenance, repair, replacement, or completion of an existing implant that was started or placed by a Non -Participating Provider without a referral from a Participating Provider. h. Maintenance, repair, replacement, or completion of an existing implant that was started or placed prior to the effective date of coverage under this Contract. i. Treatment of a primary or transitional dentition. Current Dental Terminology (CDT) 0 2020 American Dental Association. All rights reserved. 001 L-WA81 1 (5/20) 31