Common use of DENTAL NECESSITY Clause in Contracts

DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action. Please see Appeals in Section 5 for details. We may review dental necessity on a case-by-case basis. We determine dental necessity solely for purposes of claims payment based on our dental policies and related guidelines under this plan.

DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: •  consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; •  appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; •  not primarily for the convenience of the member, the member’s family or dentist of such member; and •  the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action. Please see Appeals in Section 5 for details. We may review dental necessity on a case-by-case basis. We determine dental necessity solely for purposes of claims payment based on our dental policies and related guidelines under this plan.