The UnitedHealthcare dental plan does not cover certain expenses including, but not limited to, charges for:

• Dental Services that are not necessary.
• Hospitalization or other facility charges.
• Any dental procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)
• Reconstructive Surgery regardless of whether or not the surgery which is incidental to a dental disease, injury, or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.
• Any dental procedure not directly associated with dental disease.
• Any procedure not performed in a dental setting.
• Repairs to Full Dentures, Partial Dentures, Bridges – Limited to repairs or adjustments performed more than 12 months after the initial insertion.
• Palliative Treatment – Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.
• Occlusal Guards – Covered only if prescribed to control habitual grinding, and limited to one guard every consecutive 36 months.
• Full Mouth Debridement – Limited to once every consecutive 36 months.
• General Anesthesia – Covered only where medically necessary.
• Osseous Grafts – With or without resorbable GTR membrane replacement, are limited to once every consecutive 36 months per quadrant or surgical site.
• Periodontal Surgery – Hard tissue and soft tissue periodontal surgery are limited to once every consecutive 36 months, per surgical area. This includes gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, pedicle grafts, and free soft tissue grafts.
• Replacement of Full Dentures, Partial Dentures, Bridges, or Crowns – Replacement of complete or partial dentures, both fixed and removable, or crowns, previously submitted for payment under this Plan is limited to once every consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.
• Procedures that are considered to be experimental, investigational or unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
• The fact that an experimental, investigational or unproven service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in coverage if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition.
• Services for injuries or conditions covered by Workers’ Compensation or employer liability laws, and services that are provided without cost to the covered person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.
• Expenses for dental procedures begun prior to the covered person’s eligibility with the Plan.
• Dental services otherwise covered under the policy, but rendered after the date individual coverage under the policy terminates, including dental services for dental conditions arising prior to the date individual coverage under the policy terminates.
• Services rendered by a provider with the same legal residence as a covered person or who is a member of a covered person’s family, including spouse, brother, sister, parent or child.
• Dental services provided in a foreign country, unless required as an Emergency.
• Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12-month period, the plan is responsible only for the procedures associated with the addition.
• Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been eligible for 12 continuous months.
• Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.
• Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
• Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
• Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO).
• Placement of dental implants, implant-supported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
• Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
• Billing for incision and drainage if the involved abscessed tooth is removed on the same date of service.
• Treatment of malignant or benign neoplasms, cysts, or other pathology, except excisional removal. Treatment of congenital malformations of hard or soft tissue, including excision.
• Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
• Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.
• Acupuncture, acupressure and other forms of alternative treatment.
• Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
• Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

If differences exist between this summary and the Certificate of Coverage, the Certificate will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.