• Oral surgery, limited to bony impactions of teeth, bone fractures, removal of tumors and orthodontogenic cysts or other HMO/NC pre-approved surgical procedures.
• Covered treatment for temporomandibular join dysfunction includes pre-authorized therapeutic procedures, splinting, and the use of introral prosthetic appliances when medically necessary and approved by HMO.

Limits: Non-surgical treatment of TMJ shall be limited to $3500 per member per lifetime.

Excludes:

• Dental x-rays
• All dental services related to the care, filling, removal, or replacement of teeth.
• Treatment of injuries to or diseases of the teeth and gums, including but not limited to apicoectomy (dental root resection).
• Orthodontics.
• Root canal treatment.
• Soft tissue impactions.
• Alveolectomy.
• Treatment of periodontal disease.
• Dental implants.

Excludes: Dental care, treatment, dental surgery, and dental appliances, unless otherwise covered by a supplemental policy.

• Repairs as a result of accidental injury to sound, natural, permanent, adult teeth for up to 12 months from the date of injury. Treatment must begin within 48 hours of injury.
• Follow-up care is covered only if provided by a member’s PCP or consulting specialist or nonparticipating provider with referral from a PCP and prior authorization.
• Evaluation and treatment of TMJ dysfunction when it results from congenital deformity, disease or accident.

Cost Sharing: Copayments apply.

Excludes: Routine dental care or any oral evaluation (including splints and intraoral appliances), treatment or surgery not specifically covered. Orthodontic braces, crowns, bridges, dentures, dental root form implants, root canals and other similar dental services are not covered. Nor are injuries that occur when chewing or biting.

• Dental service when medically necessary or as a result of an accidental injury.
• Emergency dental service for restoration due to trauma or accidental injuries to sound and natural teeth. Dental service provided after first office visit for consultation with specialist.
• Oral tumors and oral cysts with precertification follow-up care covered only if coordinated by a member’s PCP.
• Temporomandibular Joint Dysfunction (TMJ) covered (including splints and intraoral appliances) when it results from congenital deformity, disease, or accident.
• Surgical services for TMJ and Craniomandibular Pain Syndrome (CPS) are covered, but only if medically necessary and evidence of joint abnormality due to disease or injury from x-rays.

Limits: Injuries that occur during the act of chewing or biting are not covered.

Cost Sharing: Copayment will apply based on place of service.

Excludes: Dental care and x-rays, including shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion and any dental treatment involved in TMJ syndrome or CPS.

• Services for tumors or cysts of the mouth, fractures of the jaw or for correction of congenital malformation.
• Oral surgery is covered when an injury or accident prevents normal functioning. Treatment is required within 60 days of the accidental injury or when necessary due to injury, disease or congenital defect.
• Covers diagnostic and therapeutic procedures for bones or joints of the jaw, face or head if condition prevents normal functioning and resulted from injury, illness or congenital defects.

Excludes:

• All other dental services, including cleaning, treatment, filling, removal or replacement of teeth or tissue directly supporting the teeth, or apicoectomy (dental root resection).
• Orthodontics appliances and braces.
• Root canal treatment.
• Impacted wisdom teeth.
• Soft tissue impaction.
• Myofacial pain.
• Dysfunction examination, evaluation and treatment,
• Alveolectomy.
• Treatment of periodontal disease.
• X-rays.

• Medically necessary care in the treatment of an otherwise medical not dental condition.
• Certain medically necessary non-dental oral surgical procedures.
• Services to provide immediate emergency care for accidental dental injury (traumatic injury resulting from external blow to sound natural teeth or mouth)
• Treatment for TMJ when it results from a congenital deformity, disease or accident and is medically necessary.
• General anesthesia for dental procedures if member qualifies.

Limits: The maximum amount that OCCI will pay for all non-surgical treatments relating to TMJ disorders is $5,000 per member.

Cost Sharing: Copayments apply.

Excludes:

• Orthodontic braces.
• Crowns, bridges, inlays, partial and/or full dentures, or false teeth.
• Treatment for periodontal disease.
• Removal of impacted teeth.
• Dental root form implants.
• Root canals.
• Cosmetic treatment
• Routine dental treatment and dental x-rays.
• Shortening or elongation of the mandible or maxilla.
• Correction of malocclusion.
• Surgical orthognatics.
• Dental care except as related to adjunctive dental care or as provided in a purchased rider.
• May exclude other dental prostheses or dental devices not specifically listed above.

• Treatment of malignant and premalignant lesions, tumors and cysts.
• Repairs to sound, natural teeth as a result of accidental injury necessary to restore the level of dental function prior to injury. This includes dental procedures, surgery or orthodontic treatment and installation of crowns, dentures or bridgework.
• Root canal therapy if root damage a result of accidental injury.
• TMJ covered if caused by congenital defect or anomaly, disease or traumatic injury and prevents normal functioning.
• Anesthesia and hospital or facility charges for dental procedures for children below the age of nine years.

Limits: Injury must be incurred while covered by plan. Anesthesia for dental procedures is covered only when hospitalization is necessary due to a medical condition unrelated to the dental procedure. Examples include severe asthma or bleeding disorder. Age or anxiety does not constitute a medical condition in this circumstance.

Excludes: All other dental services, including treatment of natural cysts of dental root origin.

Excludes:

• Crowns, bridges, dentures, or other dental prosthetic devices.
• Dental restorative care.
• Periodontal care.
• Treatment of impacted wisdom teeth.
• Orthodontics.
• Orthognathic surgery, along with hospital and professional services and supplies associated with such care.
• Treatment for TMJ unless caused by disease or accident. Any treatment for TMJ, which requires prosthesis to be placed directly on the teeth, is excluded.
• Preventive dental services are excluded unless provided in a Supplemental Benefit Expansion.

Also covers procedures involving any bone or joint of the jaw, face, or head that are medically necessary to treat a condition that prevents normal functioning of that bone or joint. To be covered, the condition must have been caused by congenital deformity, disease or traumatic injury. Authorized therapeutic procedures include splinting and use of intra-oral prosthetic appliances to reposition the bones.

Excludes:

• Coverage for damage to teeth after biting into food or other substances.
• Treatment for cavities and extractions.
• Orthodontic braces.
• Crowns, bridges, dentures or false teeth.
• Treatment for periodontal disease.
• Treatment for dentigerous cysts.
• Care of the gums or bones supporting the teeth.
• Removal of impacted teeth.
• Dental root form implants.
• Root canals.
• Other general dental procedures.

Note: These services may be covered under a rider.

• Medically necessary repairs as a result of accidental injury to sound and natural teeth.
• Medically necessary evaluation and treatment of TMJ due to congenital anomaly, disease, or accident.
• Surgery for oral tumors and cysts is also provided when medically necessary.

Excludes:

• Routine dental or oral evaluation, treatment or surgery.
• Crowns, bridges, dentures, and extractions.
• Treatment of periodontal disease; dental root from implants.
• Root canals; orthodontic appliances.
• Treatment for teeth that are chipped or broken from biting or chewing.

• Emergency services performed by a dentist for treatment of any sound natural teeth resulting from traumatic injury. To be covered the dentist must certify that sound natural teeth were injured as a result of an accident and the services must be provided within six months of the injury.
• Services and supplies, and anesthesiology services recommended by participating physician, approved in advance in writing when necessary to protect the health of a member because of a specific non-dental health condition.
• Dental surgery, treatment or care when approved in advance (in writing) in accordance with eligible medical services.
• Medically necessary services provided by a participating provider for diagnosis and treatment of TMJ, when approved in advance (in writing) by UHC.

Cost Sharing: Copayments may apply.

Excludes:

• Injury from biting or chewing or for dentures.
• Dental surgery, treatment or care including treatment of overbite or underbite, removal of wisdom teeth, and maxillary, mandibulary osteotomies.
• Dental X-rays, prescriptions, diagnostic testing, supplies, appliances (including occlusal splints).
• Dentures.
• Complications arising out of such dental surgery, treatment or care (including hospitalization).

• Treatment of a fractured or dislocated jaw or damage to sound natural teeth caused by accidental injury.
• Limited coverage for removing cysts of the mouth.
• Diagnosis and treatment of TMJ or TMC by splinting, the use of intraoral prosthetic appliances to reposition the bones or surgery.

Limits:

• Treatment for injury must be sought within 72 hours of the accidental injury. Treatment of a fractured or dislocated jaw or damage to teeth will not last beyond 365 days.
• Treatment of TMJ only covered to treat a condition which prevents normal functioning of the bone or joint. The bone or joint abnormality must be caused by disease, injury, or congenital deformity. : There is a $3,500 lifetime maximum on WellPath coverage of nonsurgical treatment of the TMJ.
• Services must be provided by a participating provider with prior approval of WellPath.

Cost Sharing: Copayments may apply.

Excludes:

• Routine dental work.
• X-rays or exams.
• Crowns, bridges or dentures. Dental prostheses or cosmetic surgery for shortening or lengthening the jaw.
• Orthodontics.
• Extracting teeth.
• Treatment for periodontal disease.
• Dental root form implants or root canals.
• Removal of cysts directly related to the teeth and their supporting structures.