Common use of Limitations of Benefits for Pediatric Enrollees Clause in Contracts

Limitations of Benefits for Pediatric Enrollees. 1) The frequency of certain Benefits is limited. Frequency Limitations are listed in Schedule A, Description of Benefits and Copayments. 2) Isolated bitewing or periapical films are allowed on an emergency or episodic basis. 3) Additional coverage of Panoramic and cephalometric x-rays (D0330, D0340) is allowed as part of an initial medically necessary orthodontic treatment or on an emergency basis. 4) Sealants (D1351, D1352) are covered only on permanent molars. The teeth must be caries free with no restorations on the mesial, distal or occlusal surfaces. 5) Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 24 months of the original restoration are included, and a separate fee is not chargeable to the Enrollee by a Contract Dentist. However, coverage may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy. 6) Covered restorations includes all related services, such as etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments, and detection agents. 7) Resin restoration is a Benefit when a laboratory fabricated porcelain or resin veneer is used to restore any teeth due to tooth fracture or caries. 8) Prefabricated crowns (D2929, D2930, D2931) are covered only on primary teeth, permanent teeth through age 14, or when placed as a result of accidental injury. 9) Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or trade names at an additional fee. The Enrollee must be offered the plan Benefits of a high quality laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials) the Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Examples of material upgrade include: Captek, Procera, Lava, Empress and Xxxxx. Contact the Customer Service department at 000-000-0000 if you have questions regarding the additional fee or name brand services. 10) Onlays, permanent single crown restorations, and posts and cores for Enrollees 12 years of age or younger are excluded from coverage, unless specific rationale is provided indicating the reason for such treatment (e.g., fracture, endodontic therapy, etc.) and is approved by the plan. 11) Core buildups (D2950) can be considered for Benefits only when there is insufficient retention for a crown. A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts, box forms or concave irregularities in the preparation. 12) Replacement of crowns, inlays, onlays, buildups, and posts and cores is covered only if the existing crown, inlay, onlay, buildup, or post and core was inserted at least sixty