Experimental or Investigative: A service or supply that is determined by DeltaCare to meet any one of the following criteria. If any of these situations are met, the service or supply is considered experimental and/or investigative, and benefits will not be provided. 1. It cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration (FDA), and such approval has not been granted on the date it is furnished. 2. The provider has not demonstrated proficiency in the service, based on knowledge, training, experience and treatment outcomes. 3. Reliable evidence shows the service is the subject of ongoing clinical trials to determine its safety or effectiveness. 4. Reliable evidence has shown the service is not as safe or effective for a particular dental condition compared to other generally available services and that it poses a significant risk to the enrollee’s health or safety. Reliable evidence means only published reports and articles in authoritative dental and scientific literature, scientific results of the provider’s written protocols or scientific data from another provider studying the same service. The documentation used to establish the plan criteria will be made available for enrollees to examine at the office of DeltaCare if enrollees send written requests. If DeltaCare determines that a service is experimental or investigative, and therefore not covered, the enrollee may appeal the decision. DeltaCare will respond in writing within 20 working days after receipt of a claim or other fully documented request for benefits, or a fully documented appeal. The 20-day period may be extended only with the enrollee’s informed written consent. Group: The employer or entity that is contracting for dental benefits for its subscribers and their dependents. HCA: Health Care Authority is the Washington state agency that administers the PEBB and SEBB Programs. Licensed Professional: An individual legally authorized to perform services as defined in his/her license. Licensed professional includes, but is not limited to, denturist, hygienist and radiology technician. Benefits under this Contract will not be denied for any health care service performed by a registered nurse licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of such nurse’s license, and second, this contract would have provided benefits if such service had been performed by a doctor of medicine licensed to practice under chapter 18.71 RCW. Member: Enrollee, Subscriber, or dependent, who has completed the enrollment process. Necessary vs. Not Covered Treatment: You and your provider should discuss which services may not be Covered Dental Benefits. Not all necessary treatment is covered, and there may be additional charges. The majority of required dental services are covered by your plan. However, there are certain treatments that remain the responsibility of the patient. 1. The purpose of the service, supply or intervention is to treat a dental condition; 2. It is the appropriate level of service, supply or intervention considering the potential benefits and harm to the patient; 3. The level of service, supply or intervention is known to be effective in improving health outcomes; 4. The level of service, supply or intervention recommended for this condition is cost-effective compared to alternative interventions, including no intervention; and 5. For new interventions, effectiveness is determined by scientific evidence. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion. 2024-01-03100-BB 2 DCL 20240101