18. Replacement of an existing fixed bridge (to replace ONE missing permanent anterior tooth) is covered after five years from initial placement and only if it involves the same teeth as the prior bridge. Reconstruction 19. The DeltaCare Plan provides coverage for procedures necessary to eliminate oral disease and to replace missing teeth. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ) are not covered benefits, unless the treatment is specifically to manage a TMJ disorder and the group has TMJ benefits specifically included above. Extensive treatment plans involving 10 or more crowns or units of fixed bridgework is considered full mouth reconstruction. Confirmation of Treatment and Cost must include full treatment plan, full mouth x rays and narratives on requested treatment. Build ups will be included in the full mouth treatment plans. Maximum payable, if approved, is $3,000 annually up to $9,000 over 3 consecutive years. Specialized Techniques 20. Noble or titanium metal for removable appliances, crowns, precision abutments for partials or bridges (overlays, implants, and appliances associated therewith), personalization and characterization, are all considered optional treatment. If performed, the patient must pay the difference in cost between the dentist’s DDWA filed fees for the covered benefit and optional treatment, plus any co-payment for the covered benefit. (As long as the patient has the option of the covered benefit procedure.) Preventive Control Programs 21. Soft tissue management programs are not covered. Periodontal pocket charting, root planing/scaling/curettage, oral hygiene instruction and prophylaxis are covered benefits and, if performed as part of a soft tissue management program, will be provided for listed co-payments, if any. 22. Follow-up examinations for reevaluation, particularly periodontal reevaluation, are considered to be part of the general services rendered. Interim partials (Stayplates) 23. Interim partials (Stayplates) in conjunction with fixed or removable appliances are only a benefit to replace recently extracted anterior permanent teeth during a healing period. Frenectomy 24. The frenum can be excised when the tongue has limited mobility; or there is a large diastema between anterior teeth; or when the frenum interferes with a prosthetic appliance. Pedodontia 25. Referrals to a pediatric Dentist must be preauthorized by DeltaCare. Benefits for dependent children through age 18 are covered at 100% of the agreed upon fee less any applicable co-payments for covered benefits. Treatment Planning 26. The objective of this program is to see that all patients are brought to a good level of oral health and that this level of oral health is maintained. To achieve these objectives takes treatment planning. Priorities have been established on the following basis: a. Pain and dysfunction b. Active dental disease – active decay and periodontal disease c. Replacement of missing teeth 2024-01-03100-BB 23 DCL 20240101