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does not apply to orthodontic treatment in progress
<br />(if a Covered Service).
<br />6. Prescription drugs (except intramuscular injectable
<br />antibiotics), premedicarions, medicaments/
<br />solutions, and relative analgesia.
<br />7. General anesthesia and/or intravenous sedation for
<br />surgical procedures, unless medically necessary,
<br />or for restorative dentistry.
<br />8. Chazges for hospitalization, laboratory tests, and
<br />histopathological examinations.
<br />9. Charges for failure to keep a scheduled visit with
<br />the Dentist.
<br />10. Services or supplies, as detemvned by Delta
<br />Dental, for which no valid dental need can be
<br />demonstrated.
<br />11. Services or supplies, as determined by Delta
<br />Dental, that are investigational in nature, including
<br />services or supplies required to treat complications
<br />from investigational procedures.
<br />12. Specialized techniques, as deternuned by Delta
<br />Dental.
<br />13. Services or supplies, as deternuned by Delta
<br />Dental, which are not rendered in accordance with
<br />generally accepted standards of dental practice.
<br />14. Treatment by other than a Dentist, except for
<br />services performed by a licensed dental hygienist
<br />or other dental professional as detemuned by
<br />Delta Dental under the scope of his or her license
<br />as pernutted by applicable state law.
<br />15. Services or supplies excluded by the policies and
<br />procedures of Delta Dental, including the
<br />Processing Policies.
<br />16. Services or supplies for which no charge is made,
<br />for which the patient is not legally obligated to
<br />pay, or for which no charge would be made in the
<br />absence of Delta Dental coverage.
<br />17. Services or supplies received as a result of dental
<br />disease, defect, or injury due to an act of war,
<br />declared or undeclared.
<br />18. Services or supplies that are covered under a
<br />hospital, surgicaUmedical, or prescription drug
<br />prograin.
<br />19. Services or supplies that aze not within the
<br />categories of benefits that have been selected and
<br />that are not covered in the Plan.
<br />20. Fluoride rinses, self-applied fluorides, or
<br />desensitizing medicaments.
<br />21. Preventive control programs (including oral
<br />hygiene instruction, caries susceptibility tests,
<br />dietary control, tobacco counseling, home care
<br />medicaxnents, etc.).
<br />22. Space maintainers for maintaining space due to
<br />premature loss of anterior primary teeth.
<br />23. Lost, missing, or stolen appliances of any type and
<br />replacement or repair of orthodontic appliances or
<br />space maintainers.
<br />24. Cosmetic dentistry, as determined by Delta Dental,
<br />except that when a Child covered from the moment
<br />of birth or placement in the adoptive home requires
<br />dental care associated with congenital defects and
<br />anomalies, congenital defects will be covered to the
<br />same extent an otherwise Covered Service is
<br />provided by the Plan.
<br />25. Veneers.
<br />26. Prefabricated crowns used as final restorations on
<br />permanent teeth.
<br />27. Appliances, surgical procedures, and restorations
<br />for increasing vertical dimension; for altering,
<br />restoring, or maintaining occlusion; for replacing
<br />tooth structure loss resulting from attrition,
<br />abrasion, abfraction, or erosion; or for periodontal
<br />splinting. If orthodontic services are Covered
<br />Services, this exclusion will not apply to
<br />orthodontic services as limited by the terms and
<br />conditions of the Plan.
<br />28. Paste-type root canal fillings on permanent teeth.
<br />29. Replacement, repair, relines, or adjustments of
<br />occlusal guards.
<br />30. Chemical curettage.
<br />31. Services associated with overdentures.
<br />32. Metal bases on removable prostheses.
<br />33. The replacement of teeth beyond the normal
<br />complement of teeth.
<br />34. Personalization/characteriza.tion of any service or
<br />appliance.
<br />35. Temporary crowns used for temporization during
<br />crown or bridge fabrication.
<br />36. Posterior bridges in conjunction with partial
<br />dentures in the same arch.
<br />Form No. 1752-NC 9
<br />NCPPOpIus-A
<br />01 /2012
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