Common use of Surgical Periodontal Services Clause in Contracts

Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • apexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic therapy if You discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes: • surgical tooth extractions. • alveoloplasty and vestibuloplasty. • excision of benign odontogenic tumor/cysts. • excision of bone tissue. • incision and drainage of an intraoral abscess. • other Dentally Necessary surgical and repair procedures not specifically excluded in this contract. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical services related to a congenital malformation. • prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological), or for complete bony impactions covered by another benefit plan. • excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.

Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal Periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling Scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal Periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic Therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • apexificationApexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic Endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp Pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic Endodontic therapy if You you discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes: • surgical Surgical tooth extractions. • alveoloplasty Alveoloplasty and vestibuloplasty. • excision Excision of benign odontogenic tumor/cysts. • excision Excision of bone tissue. • incision Incision and drainage of an intraoral abscess. • other Other Dentally Necessary surgical and repair procedures not specifically excluded in this contract. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical Surgical services related to a congenital malformation. • prophylactic Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological), or for complete bony impactions covered by another benefit plan. • excision Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.

Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal Periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling Scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal Periodontal maintenance procedures –– Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic Therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • apexificationApexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic Endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp Pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic Endodontic therapy if You you discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes: • surgical Surgical tooth extractions. • alveoloplasty Alveoloplasty and vestibuloplasty. • excision Excision of benign odontogenic tumor/cysts. • excision Excision of bone tissue. • incision Incision and drainage of an intraoral abscess. • other Other Dentally Necessary surgical and repair procedures not specifically excluded in this contract. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical Surgical services related to a congenital malformation. • prophylactic Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological), or for complete bony impactions covered by another benefit plan. • excision Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.

Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal Periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling Scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal Periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic Therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-follow- up care. • apexificationApexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic Endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp Pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic Endodontic therapy if You you discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes: • surgical Surgical tooth extractions. • alveoloplasty Alveoloplasty and vestibuloplasty. • excision Excision of benign odontogenic tumor/cysts. • excision Excision of bone tissue. • incision Incision and drainage of an intraoral abscess. • other Other Dentally Necessary surgical and repair procedures not specifically excluded in this contract. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical Surgical services related to a congenital malformation. • prophylactic Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological), or for complete bony impactions covered by another benefit plan. • excision Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.

Surgical Periodontal Services. Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal Periodontal scaling and root planing – Benefits are limited to one per quadrant every 24 months. • scaling Scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime. • periodontal Periodontal maintenance procedures –Benefits are limited to four every 12 months combined with prophylaxis and must be performed following active periodontal treatment. Adjunctive Services Adjunctive general services include: • palliative Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Dentally Necessary for documented Participants with a disability or for a justifiable medical or dental condition. A person’s apprehension does not constitute Dental Necessity. • therapeutic Therapeutic parenteral drugs – Therapeutic parenteral drugs will be covered for a Participant under age 19. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root Root canal therapy, including treatment plan, clinical procedures, working and post-operative radiographs and follow-up care. • apexificationApexification/recalcification procedures and apicoectomy/periradicular services including surgery, retrograde filling, root amputation and hemisection. Benefits will not be provided for the following “Endodontic Services”: • endodontic Endodontic retreatments provided within 12 months of the initial endodontic therapy by the same Dentist on the same tooth. • pulp Pulp vitality tests, endodontic endosseous implants, intentional reimplantations, canal preparation, fitting of preformed dowel and post, or post removal. • endodontic Endodontic therapy if You discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery under local anesthetics and includes: • surgical Surgical tooth extractions. • alveoloplasty Alveoloplasty and vestibuloplasty. • excision Excision of benign odontogenic tumor/cysts. • excision Excision of bone tissue. • incision Incision and drainage of an intraoral abscess. • other Other Dentally Necessary surgical and repair procedures not specifically excluded in this contract. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical Surgical services related to a congenital malformation. • prophylactic Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathological), or for complete bony impactions covered by another benefit plan. • excision Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision Excision of exostoses of the jaws and hard palate (provided that this procedure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.

Surgical Periodontal Services. Non-surgical Non‐surgical periodontal service is the non-surgical non‐surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes: • periodontal Periodontal scaling and root planing – planing—Benefits are limited to one per quadrant quad­ rant every 24 months. • scaling in the presence of generalized moderate to severe gingival inflammation is limited to once every 6 months combined with prophylaxes and periodontal maintenance. • full Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetimeevery 12 months. • periodontal Periodontal maintenance procedures –procedures—Benefits are limited to four two every 12 months combined in combination with routine oral prophylaxis and must be performed following active periodontal treatment. Benefits will not be provided for chemical treatments, localized delivery of chemotherapeutic agents without history of active periodontal therapy, or when performed on the same date (or in close proximity) as active periodontal therapy. Adjunctive Services Adjunctive general services include: • palliative Palliative treatment (emergency) of dental pain, and when not performed in conjunction with a definitive treatment. • deep Deep sedation/general anesthesia and intravenousintravenous sedation/non-intravenous non‐intravenous conscious sedation – sedation—By report only and when determined to be Dentally Necessary medically necessary for documented Participants persons with a disability or for a justifiable medical medic­ al or dental condition. A person’s 's apprehension does not constitute Dental Necessitymedical necessity. IL‐G‐H‐OF‐2016 82 • Nitrous Oxide analgesia will be covered. • therapeutic parenteral drugs – Therapeutic parenteral drugs drug injections will be covered for a Participant under age 19covered. Benefits will not be provided for local anesthesia, nitrous oxide analgesia, anesthesia or other drugs or medicaments and/or their application. Endodontic Services Endodontics is the treatment of dental disease of the tooth pulp and includes: • therapeutic Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure. These services are considered part of the root canal procedure if root canal therapy is performed within 45 days of services. • root Root canal therapy, including treatment plan, clinical procedures, working and post-operative post‐operative radiographs and follow-up follow‐up care. • apexificationApexification/recalcification procedures and apicoectomy/periradicular services ser­ vices including surgerySurgery, retrograde retograde filling, root amputation amputations and hemisection. Pulpal debridement is considered part of endodontic therapy when performed by the same Provider and not associated with a definitive emergency visit. Benefits will not be provided for the following “Endodontic Endondontic Services”": • endodontic Endodontic retreatments provided within 12 months of the initial endodontic endodont­ ic therapy by the same Dentist on the same toothDentist. • pulp Pulp vitality tests, endodontic endosseous implants, intentional reimplantationsreimplanta­ tions, canal preparation, fitting of preformed performed dowel and post, or post removal. • endodontic Endodontic therapy if You you discontinue endodontic treatment. Oral Surgery Services Oral surgery means the procedures for surgical extractions and other dental surgery sur­ xxxx under local anesthetics and includes: • surgical Surgical tooth extractions. extraction • alveoloplasty Alveoloplasty and vestibuloplasty. vestibuloplasty • excision Excision of benign odontogenic tumor/cysts. • excision Excision of bone tissue. • incision Incision and drainage of an intraoral abscess. • other Dentally Necessary Other medically necessary surgical and repair procedures not specifically excluded in this contractCertificate. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive defin­ itive treatment of an abscess. Routine follow-up follow‐up care is considered part of the procedure. Benefits will not be provided for the following Oral Surgery procedures: • surgical Surgical services related to a congenital malformation. IL‐G‐H‐OF‐2016 83 • prophylactic Prophylactic removal of third molars or impacted teeth (asymptomatic, nonpathologicalnon­ pathological), or for complete bony impactions covered by another benefit plan. • excision Excision of tumors or cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • excision Excision of exostoses of the jaws and hard palate (provided that this procedure proced­ ure is not done in preparation for dentures or other prostheses); • treatment of fractures of facial bones; • external incision and drainage of cellulitis; • incision of accessory sinuses, salivary glands or ducts; • reduction of dislocation, or excision of the temporomandibular joints.