15. Composite bands and lingual adaptation of orthodontic bands are considered optional treatment and would be subject to additional charges. *Phase I is defined as early treatment including interceptive orthodontia prior to the development of late mixed dentition. Orthognathic Surgery Limitations 1. Services that would be provided under medical care including but not limited to, hospital and professional services. 2. Diagnostic procedures not otherwise covered under this plan. 3. Any procedures that are performed in conjunction with orthognathic surgery and are covered benefits under another portion of this plan. General Exclusions — General Anesthesia, intravenous and inhalation sedation, and the services of a special anesthesiologist, except that coverage will be provided for general anesthesia and intravenous sedation services in conjunction with any covered dental procedure performed in a dental office if such anesthesia services are medically necessary for enrolled members through age 6, or physically or developmentally disabled; — Cosmetic dental care. Cosmetic services include, but are not limited to, laminates, veneers or tooth bleaching; — Services for injuries or conditions which are compensable under Worker’s Compensation or Employers’ Liability laws, and services which are provided to the eligible person by any federal or state or provincial government agency or provided without cost to the eligible person by any municipality, county or other political subdivision, other than medical assistance in this state, under medical assistance RCW 74.09.500, or any other state, under 42 U.S.C., Section 1396a, section 1902 of the Social Security Act; — Restorations or appliances necessary to correct vertical dimension or to restore the occlusion; such procedures include restoration of tooth structure lost from attrition, abrasion or erosion without sensitivity and restorations for malalignment of teeth; — Application of desensitizing agents (treatment for sensitivity or adhesive resin application); — Experimental services or supplies. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation. — Dental services performed in a hospital and related hospital fees. However, this exclusion will not apply and benefits will be provided for services rendered during such hospital care, including outpatient charges, if all these requirements are met: a. A hospital setting for the dental care must be medically necessary. b. Expenses for such care are not covered under the enrollee’s employer-sponsored medical plan. c. Prior to hospitalization, a request for Confirmation of Treatment and Cost of dental treatment performed at a hospital is submitted to and approved by DeltaCare. Such request for Confirmation of Treatment and Cost must be accompanied by a physician’s statement of dental necessity. If hospital or facility care is approved, available benefits will be provided at the same percentage rate as those performed by a participating dental provider, up to the available benefit maximum. — Loss or theft of fixed or removable prosthetics (crowns, bridges, full or partial dentures); — Dental expenses incurred in connection with any dental procedure started after termination of eligibility of coverage; — Dental expenses incurred in connection with any dental procedure started prior to the enrollee’s eligibility (except for Orthodontic treatment plans transferred to DDWA from Willamette); — Cysts and malignancies; — Laboratory examination of tissue specimen; Laboratory tests and laboratory exams; 2024-01-03100-BB 20 DCL 20240101