Common use of Dental Services Clause in Contracts

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate servicemachine. • Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o • training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: •  Dental injuries incurred as a result of biting or chewing. •  General dental services including, but not limited to, such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. •  Panorex x-rays or dental x-rays. •  Orthodontic services, even if related to a covered surgery. •  Dental appliances or devices. •  Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. •  The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate servicemachine. •  Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate servicemachine. • Dialysis services received in a physician’s office. Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) • Items typically found in the home that do not need a prescription and are easily obtainable such as, but not limited to: o adhesive bandages; o elastic bandages; o gauze pads; and o alcohol swabs. • DME and medical supplies prescribed primarily for the convenience of the member or the member’s family, including but not limited to, duplicate DME or medical supplies for use in multiple locations or any DME or medical supplies used primarily to assist a caregiver. • Non-wearable automatic external defibrillators. • Replacement of durable medical equipment and prosthetic devices prescribed because of a desire for new equipment or new technology. • Equipment that does not meet the basic functional need of the average person. • DME that does not directly improve the function of the member. • Medical supplies provided during an office visit. • Pillows or batteries, except when used for the operation of a covered prosthetic device, or items for which the sole function is to improve the quality of life or mental wellbeing. • Repair or replacement of DME when the equipment is under warranty, covered by the manufacturer, or during the rental period. • Infant formula, nutritional supplements and food, or food products, whether or not prescribed, unless required by R.I. Law §27-20-56 for Enteral Nutrition Products, or delivered through a feeding tube as the sole source of nutrition. • Corrective or orthopedic shoes and orthotic devices used in connection with footwear, unless for the treatment of diabetes. • Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigational except as described in Section 3. • Reversal of gender reassignment surgery.

Dental Services. The following This agreement does NOT cover: • general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. ; • Panorex xpanorex X-rays or dental xX-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. See Section 3.12 - Hospital Emergency Room Services for details); • Orthodontic orthodontic services, even if related to a covered surgery. ; • Dental dental appliances or devices; and • hospital services, free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o • alveoloplasty, each quadrant; o • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following This agreement does NOT cover: • general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x, panorex X-rays or dental x-X- rays. ; • Orthodontic dental appliances/devices; • hospital services, even if related free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when we determine the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is determined to a covered surgerybe not medically necessary. • Dental appliances or devices. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and and/or dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty• alveoplasty, each quadrant; o . • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate servicemachine. • Dialysis services received in a physician’s office.p h y s i coffiicea. n ’ s

Dental Services. The following This agreement does NOT cover:  general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x;  panorex X-rays or dental xX-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. • Orthodontic See Section 3.17 - Hospital Emergency Room Services for details);  orthodontic services, even if related to a covered surgery. • Dental ;  dental appliances or devices; and  hospital services, free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o  apicoectomy, per tooth, first root; o  alveolectomy including curettage of osteitis or sequestrectomy; o  alveoloplasty, each quadrant; o  complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o  excision of feberous tuberosities; o  excision of hyperplastic alveolar mucosa, each quadrant; o  operculectomy excision periocoronal tissues; o  removal of partially bony impacted tooth; o  removal of completely bony impacted tooth, with or without unusual surgical complications; o  surgical removal of partial bony impaction; o  surgical removal of impacted maxillary tooth; o  surgical removal of residual tooth roots; and o or  vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following Except for those dental services are not listed as covered, except as described under Dental Services in (see Section 33.6), this agreement does NOT cover: • Dental injuries incurred as a result of biting or chewing. • General general dental services including, but not limited to, such as extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. ; • Panorex panorex x-rays or dental x-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. See Section 3.12 - Emergency Services for details); • Orthodontic orthodontic services, even if related to a covered surgery. , unless specifically noted in the Summary of Medical Benefits ; • Dental dental appliances or devices; and • hospital services, freestanding ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or freestanding ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o • alveoloplasty, each quadrant; o • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following This agreement does NOT cover:  general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x;  panorex X-rays or dental xX-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. • Orthodontic See Section 3.12 - Hospital Emergency Room Services for details);  orthodontic services, even if related to a covered surgery. • Dental ;  dental appliances or devices; and  hospital services, free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o  apicoectomy, per tooth, first root; o  alveolectomy including curettage of osteitis or sequestrectomy; o  alveoloplasty, each quadrant; o  complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o  excision of feberous tuberosities; o  excision of hyperplastic alveolar mucosa, each quadrant; o  operculectomy excision periocoronal tissues; o  removal of partially bony impacted tooth; o  removal of completely bony impacted tooth, with or without unusual surgical complications; o  surgical removal of partial bony impaction; o  surgical removal of impacted maxillary tooth; o  surgical removal of residual tooth roots; and o or  vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following This agreement does NOT cover: • general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. ; • Panorex xpanorex X-rays or dental xX-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. See Section 3.11 - Emergency Services for details); • Orthodontic orthodontic services, even if related to a covered surgery. ; • Dental dental appliances or devices; and • hospital services, free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o • alveoloplasty, each quadrant; o • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following Except for those dental services are not listed as covered, except as described under Dental Services in (see Section 33.6), this agreement does NOT cover: • Dental injuries incurred as a result of biting or chewing. • General general dental services including, but not limited to, such as extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. ; • Panorex panorex x-rays or dental x-raysrays (except when ordered by a doctor or dentist to diagnose a condition due to an accident to your sound natural teeth. See Section 3.12 - Emergency Room Services for details); • Orthodontic orthodontic services, even if related to a covered surgery. , unless specifically noted in the Summary of Medical Benefits; • Dental dental appliances or devices; and • hospital services, freestanding ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or freestanding ambulatory surgi-center or the setting in which the services are received is not medically necessary. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o • alveoloplasty, each quadrant; o • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following This agreement does NOT cover: • general dental services are not covered, except such as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions (including full mouth extractions), prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x, panorex X-rays or dental x-X- rays. ; • Orthodontic services, orthodontic services even if related to a covered surgery; • dental appliances/devices; • hospital services, free-standing ambulatory surgi-center services, and anesthesia services provided in connection with a dental service when the use of the hospital or free-standing ambulatory surgi-center or the setting in which the services are received is determined to be not medically necessary. • Dental appliances or devices. • Preparation This agreement does NOT cover any preparation of the mouth for dentures and and/or dental or oral surgeries such as, but not limited to, the following: o • apicoectomy, per tooth, first root; o • alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty• alveoplasty, each quadrant; o . • complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o • excision of feberous tuberosities; o • excision of hyperplastic alveolar mucosa, each quadrant; o • operculectomy excision periocoronal tissues; o • removal of partially bony impacted tooth; o • removal of completely bony impacted tooth, with or without unusual surgical complications; o • surgical removal of partial bony impaction; o • surgical removal of impacted maxillary tooth; o • surgical removal of residual tooth roots; and o or • vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

Dental Services. The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.