Download pdf - FEDVIP Select Standard - 704xs - Dominion National · BRIDGE/PONTICS D6010 Endosteal ... to high noble metal FPD ..... 843 D6070 Abutment supp. retainer for porc. fused to predom

D2980-83 Crown, inlay, onlay or veneer repair............................... 107D2990 Resininfiltration/smoothsurface ...................................... 28

PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular ...................... 702 D5130/40 Immediatedenture-maxillary/mandibular ..................... 758 D5211/12 Maxillary/mandibularpartialdenture-resinbase ..........477D5213/14 Maxillary/mandibularpartialdenture-castmetal .......... 802 D5281 Rem.unilateralpartialdenture-onepiececastmetal ...428D5410/11 Adjustcompletedenture-maxillary/mandibular .............. 30 D5421/22 Adjustpartialdenture-maxillary/mandibular ................... 30 D5510/5610 Repairbrokendenturebase(complete/resin) ..................56D5520 Replacemissingorbrokenteeth-completedenture ......56D5620 Repaircastframework .....................................................56D5630 Repairorreplacebrokenclasp ........................................ 81D5640 Replacebrokenteeth-pertooth .....................................56D5650/60 Addtoothorclasptoexistingpartialdenture ...................56D5670/71 Replaceallteethandacryliconcastmetalframework- maxillary/mandibular ...................................................326D5710/11 Rebasecompletemaxillary/mandibulardenture ............184D5720/21 Rebasemaxillary/mandibularpartialdenture .................184D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ...111 D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) ..111 D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ......165D5760/61 Relinemaxillary/mandibularpartialdenture(lab) ...........165D5850/51 Tissueconditioning-maxillary/mandibular ......................56

BRIDGE/PONTICSD6010 Endostealimplant-surgicalplacement ....................... 1292 D6011 Secondstageimplantsurgery ...................................... 200D6013 Surgicalplacementofminiimplant ...............................431D6055 Connectingbar-implantorabutmentsupported ......... 1213 D6056 Prefabr.abutment-incl.modificationandplacement ....343D6057 Customfabricatedabutment-incl.modification/placement ...491D6058 Abutmentsupportedporcelain/ceramiccrown ............... 851 D6059 Abutmentporc/metalcrown-highnoblemetal ................846D6060 Abutmentporc/metalcrown-pred.basemetal ...............754D6061 Abutmentporc/metalcrown-noblemetal ......................796D6062 Abutmentsupp.casthighnoblemetalcrown ................834D6063 Abutmentsupp.castpredom.metalcrown ....................742D6064 Abutmentsupp.castnoblemetalcrown ........................776D6065 Implantsupp.porcelain/ceramiccrown .......................... 891 D6066 Implantporc/metalcrown-titanium/alloy/noble ............... 895D6067 Implantsupp.metalcrown- titanium/titaniumalloy/highnoblemetal .....................865D6068 Abutmentsupp.retainerforporc./ceramicFPD ............. 788D6069 Abutmentsupp.retainerforporc.fused tohighnoblemetalFPD ............................................843D6070 Abutmentsupp.retainerforporc.fused topredom.basemetalFPD .......................................695D6071 Abutmentsupp.retainerforporc.fusedtonoblemetalFPD ...704D6072 Abutmentsupp.retainerforcasthighnoblemetalFPD .... 788 D6073 Abutmentsupp.retainerforcastpredom.basemetalFPD ..749D6074 Abutmentsupp.retainerforcastnoblemetalFPD ........ 758 D6075 Implantsupp.retainerforceramicFPD .........................874D6076 Implantsupp.retainerforporcelainfused totitanium/titaniumalloy/highnoblemetalFPD ......... 823D6077 Implantsupp.retainerforcast titanium/titaniumalloy/highnoblemetalFPD ............. 872 D6080 Implantmaintenanceprocedures .....................................61D6081 Scalinganddebridementinthepresenceofinflammation ormucositisofasingleimplant,includingcleaningof theimplantsurfaces,withoutflapentryandclosure .........71 D6090 Repairimplantprosthesis ..............................................362D6091 Replacementofsemi-precisionorprecisionattachment ....34D6094 Abutmentsupp.crown-titanium ................................... 553 D6095 Repairimplantabutment ................................................ 391 D6100 Implantremoval .............................................................241D6194 Abutmentsupp.retainercrownforFPD-titanium .........741D6210-14 Pontic-castmetal .........................................................543D6240/41/42 Pontic-porcelainfusedmetal ........................................ 555 D6245 Pontic-porcelain/ceramic ..............................................609D6545 Retainer-castmetalforresinbondedfixedprosthesis ...260D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis ...396

D9439 Officevisit ........................................................................ 10 DIAGNOSTIC/PREVENTIVEPreventionReward:EachfamilymemberenrolledwithDominionwhoreceivescleaningsduringtheplanyearwillbereimbursedfortheir$10officevisitcopaymentsmadetothedentistatthetimeofservice(uptotwocleaningsperplanyear–atotalreimbursementofupto$20).Dominionwillsubmitacheckforthereimbursement(s)totheprimarysubscriberattheendoftheplanyear.D0120 Periodicoraleval-establishedpatient .............................. 0 D0140 Limitedoraleval-problemfocused ................................... 0 D0145 Oralevalforapatientunder3yearsofage ....................... 0 D0150 Comprehensiveoraleval-neworestablishedpatient ...... 0 D0160 Detailedandextensiveoraleval-problemfocused ........ 30 D0180 Comp.periodontaleval-neworestablishedpatient ......... 0 D0210 Intraoral-completeseries(includingbitewings) ................ 0 D0220 Intraoral-periapicalfirstfilm .............................................. 0 D0230 Intraoral-periapicaleachadd.film .................................... 0 D0240 Intraoral-occlusalfilm ....................................................... 0 D0250 Extraoral-firstfilm ............................................................. 0 D0270-74 Bitewingx-rays-1to4films .............................................. 0 D0277 Verticalbitewings-7to8films ........................................... 0 D0330 Panoramicfilm ................................................................... 0 D0425 Cariessusceptibilitytests ................................................... 0 D1110 Prophylaxis(cleaning)-adult ............................................. 0 D1110* Additionalcleaning(expectingmothersorDiabetics) ......40D1120 Prophylaxis(cleaning)-child ............................................. 0 D1206 Topicalfluoridevarnishformod/highriskcariespatients ... 0 D1208 Topicalapplicationoffluoride ............................................. 0 D1351 Sealant-pertooth ............................................................. 0 D1352 Prevresinrest.mod/highcariesrisk–perm.tooth ............ 0 SPACEMAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral ................. 0 D1515/25 Spacemaintainer-fixed/removable-bilateral ................... 0 D1550 Re-cementationofspacemaintainer ................................. 0D1575 Distalshoespacemaintainer–fixed–unilateral ............... 0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm. ...........................48D2150 Amalgam-twosurfaces,prim.orperm. ..........................62D2160 Amalgam-threesurfaces,prim.orperm. .......................76D2161 Amalgam->=4surfaces,prim.orperm. ......................... 90 RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED) D2330 Resin-basedcomposite-onesurface,anterior ............... 55 D2331 Resin-basedcomposite-twosurfaces,anterior ..............68D2332 Resin-basedcomposite-threesurfaces,anterior ........... 81 D2335 Resin-basedcomposite->=4surfaces,anterior ............. 83 D2391 Resin-basedcomposite-onesurface,posterior .............61D2392 Resin-basedcomposite-twosurfaces,posterior ............ 78 D2393 Resin-basedcomposite-threesurfaces,posterior .........96D2394 Resin-basedcomposite->=4surfaces,posterior ......... 110 D2951 Pinretention-pertooth,inadditiontorestoration ........... 18 CROWN & BRIDGED2510 Inlay-metallic-onesurface .......................................... 385 D2520 Inlay-metallic-twosurfaces .........................................444D2530 Inlay-metallic-threeormoresurfaces .........................487D2542 Onlay-metallic-twosurfaces .........................................497D2543 Onlay-metallic-threesurfaces ......................................544D2544 Onlay-metallic-fourormoresurfaces ........................... 559 D2740 Crown-porcelain/ceramicsubstrate .............................609D2750/51/52 Crown-porcelainfusedmetal ....................................... 555 D2780/81/82 Crown-3/4castwithmetal ............................................ 519 D2783 Crown-3/4porcelain/ceramic .......................................549D2790-94 Crown-fullcasthighnoblemetal ..................................543D2910/20 Recementinlay,onlay/crownorpartialcoveragerest. .... 38 D2930/31 Prefab.stainlesssteelcrown-prim./perm.tooth ........... 100 D2941 Interimtherapeuticrestoration,primarydentition ............24D2950 Corebuildup,includinganypins .................................... 133 D2954 Prefab.postandcoreinadditiontocrown .....................164

FEDVIP Select Standard - 704xsDescription of Benefits & Member Copayments

ADA MEMBERCODE BENEFIT COPAYMENT(S)


Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused. 2018

D6601 Inlay-porc./ceramic,>=3surfaces ................................354D6604 Inlay-castpredominantlybasemetal,twosurfaces .....236D6605 Inlay-castpredominantlybasemetal,>=3surfaces ..... 302 D6613 Onlay-castpredominantlybasemetal,>=3surfaces ... 332 D6740 Crown-porcelain/ceramic .............................................609D6750/51/52 Crown-porcelainfusedmetal ....................................... 555 D6780/81/82 Crown-3/4castmetal ................................................... 519 D6783 Crown-3/4porc./ceramic ..............................................549D6790-94 Crown-fullcastmetal ...................................................543D6930 Recementfixedpartialdenture ........................................ 58 D6980 Fixedpartialdenturerepair,byreport ............................ 172 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain ...............43D9223 Deepsedation/generalanesthesia –each15minuteincrement ...................................... 119D9243 Intravenousmoderate(conscious)sedation/analgesia –each15minute ....................................................... 114D9310 Consultation(diagnosticservicebynontreatingdentist) .... 0 D9440 Officevisit-afterregularlyscheduledhours .................... 10 D9610 Therapeuticdruginjection,byreport ............................... 31D9612 Therapeuticparenteraldrugs,2ormoreadminis.,diff.meds. ..49D9930 Treatmentofcomplications(post-surgical) ......................43D9941 Fabricationofathleticmouthguard ...................................65D9972/73/75 INTERNAL/EXTERNALBLEACHING-15%DISCOUNT FROMPARTICIPATINGDENTIST’SUCRFEED9974 Internalbleaching-pertooth ............................................ 131D9986 Missedappointment ......................................................... 50 D9999 Unspecifiedadjunctiveprocedure,byreport ...................... 0D9995 Teledentistry–synchronous;real-timeencounter (whenavailable) .................................................................20D9996 Teledentistry–asynchronous;informationstoredand forwardedtodentistforsubsequentreview (whenavailable) .................................................................20

ENDODONTICS1

D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) .............. 29 D3220 Therapeuticpulpotomy(excl.finalrestor.) ....................... 72 D3221 Pulpaldebridement,prim.andperm.teeth ......................76D3222 Partialpulp.forapexogenesis- perm.teethw/incomp.rootdevelop. ...........................96D3230/40 Pulpaltherapy-anterior/posterior, prim.tooth(excl.finalrest.) ..........................................96D3310 Endodontictherapy,anteriortooth ................................. 391 D3320 Endodontictherapy,bicuspidtooth ................................467D3330 Endodontictherapy,molar ............................................. 587 D3346 Retreatofprev.rootcanaltherapy,anterior ...................493D3347 Retreatofprev.rootcanaltherapy,bicuspid ..................569D3348 Retreatofprev.rootcanaltherapy,molar ......................686D3351 Apexification/recalcification–initialvisit ....................... 170D3352 Apexification/recalcification-interimmed.replacement ...496D3353 Apexification/recalcification-finalvisit ........................... 378 D3355 Pulpalregeneration-initialvisit .................................... 170D3356 Pulpalregeneration-interimmedicationreplacement ..496D3357 Pulpalregeneration-completionoftreatment .............. 200D3410 Apicoectomy,anterior.....................................................416D3421 Apicoectomy,bicuspid(firstroot) ....................................454D3425 Apicoectomy,molar(firstroot) ....................................... 511 D3426 Apicoectomy-(eachadd.root) ......................................167D3427 Periradicularsurgeryw/oapicoectomy .........................344D3428 Bonegraftinconj.w/periradicularsurg., pertooth,singlesite ...................................................574D3429 Bonegraftinconj.w/periradicularsurg., add.contiguoustooth,samesite ...............................449D3430 Retrogradefilling-perroot ............................................ 123 D3431 Biologicmaterialstoaidsoft/osseoustissue regen.inconj.w/periradicularsurg. ..........................294D3432 Guidedtissueregen.,resorbablebarrier, persite,inconj.w/periradicularsurg. ....................... 590D3450 Rootamputation-perroot .............................................264D3920 Hemisection,notinc.rootcanaltherapy ........................226 PERIODONTICS1

D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad. . 351 D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad. .... 120 D4212 Gingivectomyorgingivoplasty-w/rest.proc.,pertooth ...40D4240 Gingivalflapproc.,inc.rootplaning- >3cont.teeth,perquad ............................................. 373D4241 Gingivalflapproc,inc.rootplaning- <=3cont.teeth,perquad ...........................................234

FEDVIP Select Standard - 704xs

D4249 Clinicalcrownlengthening-hardtissue .......................... 531 D4260 Osseoussurgery->3cont.teeth,perquad...................632D4261 Osseoussurgery-<=3cont.teeth,perquad ................ 531 D4268 Surgicalrevisionproc.,pertooth ................................... 522 D4270 Pediclesofttissuegraftprocedure ................................. 592D4273 Subepithelialconnectivetissuegraftproc. (incl.donorsitesurgery) ............................................ 738 D4275 Softtissueallograft ........................................................613D4276 Comb.connectivetissue/doublepediclegraft,pertooth ...672D4277 Freesofttissuegraftprocedure, firstoredentuloustoothpositioninagraft .................654D4278 Freesofttissuegraftprocedure,eachadd.contiguous oredentuloustoothpositioninagraftsite ................... 100 D4341 Perioscalingandrootplaning->3contteeth,perquad. .. 105 D4342 Perioscalingandrootplaning-<=3teeth,perquad ...... 71D4346 Scalinginpresenceofgeneralizedmoderateorsevere gingivalinflammation–fullmouth,afteroralevaluation ..48D4355 Fullmouthdebridement ................................................... 95 D4381 Localizeddeliveryofchemotherapeuticagents ............... 25 D4910 Periodontalmaintenance .................................................56D9940 Occlusalguard,byreport ............................................... 285 ORAL SURGERY1

D7111 Extraction,coronalremnants-deciduoustooth ...............45D7140 Extraction,eruptedtoothorexposedroot ........................ 58 D7210 Eruptedtoothreq.bonecut ........................................... 107 D7220 Removalofimpactedtooth-softtissue ......................... 132 D7230 Removalofimpactedtooth-partiallybony .................... 170 D7240 Removalofimpactedtooth-completelybony ............... 200D7241 Removalofimpactedtooth- completelybony,withunusualsurg.complications ... 220 D7250 Removalofresidualtoothroots ..................................... 112 D7251 Coronectomy–intentionalpartialtoothremoval ............ 112 D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth .. 171 D7280 Exposureofanuneruptedtooth ..................................... 182 D7310 Alveoloplastyinconj.withext.-4ormoreteeth,perquad ...96D7311 Alveoloplastyinconj.w/extractions- 1-3teeth/toothspaces,perquad. .............................. 82D7320 Alveoloplastynotinconj.withextractions- 4ormoreteeth,perquad .......................................... 114D7321 Alveoloplastynotinconj.w/extractions- 1-3teeth/toothspaces,perquad. .............................. 93 D7471 Removalofexostosis .....................................................206D7510 Incisionanddrainageofabscess-intraoralsofttissue ..... 82 D7910 Sutureofrecentsmallwoundsupto5cm .......................34D7921 Collect-applyautologousproduct ...................................40D7971 Excisionofpericoronalgingiva ........................................ 77 D7999 Unspecifiedoralsurgeryprocedure,byreport ................... 0 ORTHODONTICSD8010 Limitedortho.treatment-primarydentition .................1045D8020 Limitedortho.treatment-transitionaldentition .............1236D8030 Limitedortho.treatment-adolescentdentition ............1664D8050 Interceptiveortho.treatment-primarydentition ..........1568D8060 Interceptiveortho.treatment-transitionaldentition ..... 1508 D8070* Comp.ortho.treatment-transitionaldentition .............3304D8080* Comp.ortho.treatment-adolescentdentition .............3422D8090* Comp.ortho.treatment-adultdentition ......................3658D8210 Removableappliancetherapy .......................................620D8220 Fixedappliancetherapy .................................................630D8660 Pre-orthodontictreatmentvisit ......................................... 78 D8670 Periodicortho.treatmentvisit(aspartofcontract) ........ 118 D8680 Ortho.retention(rem.ofappl.andplacementofretainer(s))... 157 D8690 Ortho.treatment(alternativebillingtoacontractfee) ....504

* Invisalign - 15% discount from participating dentist’s UCR fee.

OnlycurrentADACDTcodesareconsideredvalidbyDominionDentalServices,Inc.

Current Dental Terminology © American Dental Association.

1Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. Referrals to a specialist must be made by a member’s Participating General Dentist. See Plan Exclusion #13.



Plan Exclusions1. ServiceswhicharecoveredunderMedicare,worker’scompensationoremployer’sliabilitylaws.2. Serviceswhicharenotnecessaryforthepatient’sdentalhealthasdeterminedbythePlan.3. Cosmetic,electiveoraestheticdentistryexceptasrequiredduetoaccidentalbodilyinjurytosoundnaturalteethasdeterminedbythePlan.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Serviceswithrespecttomalignancies,cystsorneoplasms,hereditary,congenital,anodontic,mandibularprognathismordevelopment malformationswhere,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic,war,actsofwar,whetherdeclaredorundeclared.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withthe exceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder).13. ServicesperformedbyaParticipatingSpecialistwithoutareferralfromaParticipatingGeneralDentist(withtheexceptionof orthodontics).14. Electivesurgeryincluding,butnotlimitedto,extractionofnon-pathologic,asymptomaticimpactedteeth.15. Plaquecontrolprograms,oralhygieneinstruction,anddietaryinstructions.16. Nitrousoxideandoralsedation.

FEDVIP Select Standard - 704xs Exclusions

Plan Limitations1. Two(2)evaluationsarecoveredpercalendaryearincludingamaximumofone(1)comprehensiveevaluation.Alloralevaluations willbeconsideredintegralwhenprovidedonthesamedateofservicebythesamedentist.2. One(1)problemfocusedexamiscoveredpercalendaryear,perpatient.3. Two(2)teethcleanings(prophylaxis)arecoveredpercalendaryear,perpatient(one(1)additionalcleaningiscoveredduringpregnancy andfordiabeticpatients).Periodontalscalinginthepresenceofgingivalinflammationisconsideredtobearoutineprophylaxisandpaid assuch.4. Two(2)topicalfluoridesorfluoridevarnishesarecoveredpercalendaryear,perpatient.5. Two(2)bitewingx-raysarecoveredpercalendaryear,perpatient.6. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeverythree(3)years,perpatient.7. One(1)sealantpertoothiscoveredper36months,uptoage18(limitedtopermanent1stand2ndmolars).Sealantswitharestoration onsamedateofserviceareconsideredintegral.8. Distalshoespacemaintainerlimitedtoonceperlifetime.9. Replacementofafillingiscoveredifitismorethantwo(2)yearsfromthedateoforiginalplacement.10. Replacementofabridge,crownordentureiscoveredifitismorethanfive(5)yearsfromthedateoforiginalplacement.11. Crown,implantandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan.Additional crown,implantorbridgeunits,beginningwiththesixthunit,areavailableattheprovider’sUsual,Customary,andReasonable(UCR) fee,minus25%.12. One(1)reliningandrebasingofdenturesiscoveredevery36months,perpatient.13. Retreatmentofrootcanaliscoveredifitismorethantwo(2)yearsfromtheoriginaltreatment.14. Pulpotomiesareconsideredintegralwhenperformedbythesamedentistwithina45-dayperiodpriortothecompletionofrootcanal therapy.15. One(1)rootplaningorscalingiscoveredevery24monthsperquadrant,perpatient.Periodontalscalingandrootplaningprovidedwithin 24monthsofperiodontalscalingandrootplaning,orperiodontalsurgicalprocedures,inthesameareaofthemouthisnotcovered.16. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1110/D1120,limitedtooncepertwoyears.17. One(1)fullmouthdebridementiscoveredperlifetime,perpatient.18. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthree(3)teethperquadrantoratotalof12teethforallfour(4)quadrants pertwelve(12)months.Musthavepocketdepthsoffive(5)millimetersorgreater.19. One(1)periodontalsurgeryofanytype,includinganyassociatedmaterial,iscoveredevery36monthsperquadrantorsurgicalsite.20. Periodontalmaintenanceafteractivetherapyiscoveredtwo(2)timespercalendaryear,within24monthsafterdefinitiveperiodontal therapy.21. Stainlesssteelcrowns(D2930,D2931)arecoveredthroughage14,orwhenplacedasaresultofaccidentalinjuryandonepertooth,per lifetime.22. Onlays,crowns,andpostsandcoresformembers12yearsofageoryoungerareexcludedfromcoverage,unlesspre-approvedby Plan.Castpostsandcores(D2952)areprocessedasanalternatebenefitofaprefabricatedpostandcore.Postsareeligibleonlywhen providedaspartofacrownbuilduporimplantandareconsideredintegraltothebuilduporimplant.23. Fixedpartialdentures,buildupsandpostsandcoresformembersunder16yearsofagearenotcoveredunlessapprovedbyPlan.24. Surgicalperiodontalproceduresorscalingandrootplaninginthesameareaofthemouthwithin24monthsofagingivalflapprocedure arenotcovered.25. Osseoussurgeryisnotcoveredwhenprovidedwithin24monthsofosseoussurgeryinthesameareaofthemouth.26. Surgicalrevisionprocedure(D4268)isconsideredintegraltoallotherperiodontalprocedures.27. One(1)scalinganddebridementinthepresenceofinflammationormucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure,pertwo(2)years.28. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime.29. Removalofimpactedthirdmolarsinpatientsunderage15andoverage30isnotcoveredunlessapprovedbythePlan.30. Deepsedation/generalanesthesiaandintravenousconscioussedationarecovered(byreport)onlywhenprovidedinconnectionwith acoveredprocedure(s)whendeterminedtobemedicallyordentallynecessaryfordocumentedhandicappedoruncontrollablepatientsor justifiablemedicalordentalconditions31. Occlusalguardsarecoveredbyreportforpatients13yearsofageorolderwhenthepurposeoftheocclusalguardisforthetreatment ofbruxismordiagnosesotherthantemporomandibularjointdysfunction(TMJD).Occlusalguardsarelimitedtoone(1)per12consecutive monthperiod.32. Athleticmouthguardsarelimitedtoone(1)per12consecutivemonthperiod.33. TheInvisalignsystemisadiscountedbenefitthatappliestoD8070,D8080andD8090.Additionalcostsincurredwillbecomethepatient’s responsibility.34. Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwo(2)percalendaryear(whenavailable).

FEDVIP Select Standard - 704xs Limitations