Common use of Diagnostic and Preventive Services Clause in Contracts

Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for three (3) or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages nineteen (19) and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. Fluoride Treatment Limited to Members under age fourteen (14), and Limited to one (1) every twelve (12) months. Sealants Limited to children under sixteen (16) years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to two (2) per twelve (12) months in combination with pulpal debridement

Diagnostic and Preventive Services. 1. Routine Oral Exams and Consultations Consultations a. Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months months b. Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for three (3) 3 or more years. . c. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. . d. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. . e. Consultations are diagnostic services provided by a Dentist dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. 2. Oral Radiographs (x-rays) ) a. Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. . b. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages nineteen (19) 19 and older. . c. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. . d. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. 3. Oral Cleanings (Prophylaxis) ) a. Limited to two (2) every twelve (12) months. b. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy 4. Fluoride Treatment Treatment a. Limited to Members under age fourteen (14), and b. Limited to one (1) every twelve (12) months. 5. Sealants Sealants a. Limited to children under sixteen (16) 16 years old, and only for permanent first and secondary molars, and and b. Limited to one per tooth every three (3) years. 6. Emergency (Palliative) Treatment Limited to two (2) 2 per twelve (12) 12 months in combination with pulpal debridement

Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for three (3) 3 or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages nineteen (19) 19 and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy Fluoride Treatment Limited to Members under age fourteen (14), and Limited to one (1) every twelve (12) months. Sealants Limited to children under sixteen (16) 16 years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 per 12 months in combination with pulpal debridement Space Maintainers Limited to Members under age 14. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Restorations (amalgam and resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontal scaling and root planing limited to one (1) every twenty four (24) months for eac h area of the mouth. Periodontal maintenance following active periodontal therapy limited to two (2) per every twelve (12) months in combination addition to routine Prophylaxis. Surgical Periodontics Surgical periodontal procedures limited to one (1) every thirty six (36) months for each area of the mouth. Guided tissue regeneration limited to one (1) for each tooth per lifetime. Gingival flap procedure limited to one every thirty six (36) months; Clinical crown lengthening, limited to one (1) for each tooth per lifetime; Osseous surgery, limited to one (1) every thirty six (36) months; Pedicle soft tissue graft, limited to one every 36 months; Free soft tissue graft, limited to one every 36 months; Subepithelial connective tissue graft, limited to one every 36 months; Full mouth debridement to enable comprehensive evaluation and diagnosis, limited to one (1) per lifetime. Simple Extractions Surgical Extractions Surgical removal of erupted tooth with pulpal debridementelevation of mucoperiosteal flap and removal of bone and/or section of tooth. Removal of impacted tooth; Surgical removal of residual tooth roots; Coronectomy-intentional partial tooth removal; Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; Surgical access to an unerupted tooth; Alveoloplasty in conjunction with extraction; Removal of exostosis; Excision of pericoronal gingiva. General Anesthesia/Sedation If used in conjunction with certain eligible oral surgery services. Limited to sixty (60) minutes per session. Crown Repairs Recementation, restoration and pin retention Limited to one (1) every three (3) years. During the first twelve (12) months following insertion of any preventive, restorative or prosthodontics service by the same Provider, this benefit is considered included in the preventive, restorative or prosthodontics service benefit. Adjustments and Repairs of Prosthetics

Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for three (3) 3 or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages nineteen (19) 19 and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. Fluoride Treatment Limited to Members under age fourteen (14), and Limited to one (1) every twelve (12) months. Sealants Limited to children under sixteen (16) 16 years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 per 12 months in combination with pulpal debridement Space Maintainers Limited to Members under age 14. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Restorations (amalgam and resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Basic restorations will not be covered if replaced within twenty four (24) months of previous placement of any basic restoration. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontal scaling and root planing limited to one (1) every twenty four (24) months for each area of the mouth. h. Periodontal maintenance following active periodontal therapy limited to two (2) per every twelve (12) months in combination addition to routine Prophylaxis. Surgical Periodontics Surgical periodontal procedures limited to one (1) every thirty six (36) months for each area of the mouth. Guided tissue regeneration limited to one (1) for each tooth per lifetime. Gingival flap procedure limited to one every thirty six (36) months; Clinical crown lengthening, limited to one (1) for each tooth per lifetime; Osseous surgery, limited to one (1) every thirty six (36) months; Pedicle soft tissue graft, limited to one every 36 months; Free soft tissue graft, limited to one every 36 months; Subepithelial connective tissue graft, limited to one every 36 months; Full mouth debridement to enable comprehensive evaluation and diagnosis, limited to one (1) per lifetime. Simple Extractions Surgical Extractions Surgical removal of erupted tooth with pulpal debridementelevation of mucoperiosteal flap and removal of bone and/or section of tooth. Oral Surgery Removal of impacted tooth; Surgical removal of residual tooth roots; Coronectomy-intentional partial tooth removal; Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; Surgical access to an unerupted tooth; Alveoloplasty in conjunction with extraction; Removal of exostosis; Excision of pericoronal gingiva. 40XX1984 R01/22 18 10. (1) b. (a) (b)