Please also see: — Refer to “Class III Restorative” for more information regarding coverage for crowns (other than stainless steel), inlays, veneers or onlays. *Limitations for Restorative fillings do not apply to treatment received due to an emergent care situation. Please refer to the “Emergency Care” section for more information. Class II Oral Surgery Covered Dental Benefits — Major and minor oral surgery which includes the following general categories: o Removal of teeth o Preprosthetic surgery o Treatment of pathological conditions o Traumatic facial injuries o Ridge extension for insertion of dentures (vestibuloplasty) — Refer to “Class II Sedation” for Sedation information. Exclusions — Iliac crest or rib grafts to alveolar ridges — Tooth transplants — Materials placed in tooth extraction sockets for the purpose of generating osseous filling Class II Periodontics Covered Dental Benefits — Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth — Services covered include: o Periodontal scaling/root planing o Periodontal surgery o Limited adjustments to occlusion (eight teeth or fewer) o Localized delivery of antimicrobial agents o Gingivectomy *Note: Some benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a Confirmation of Treatment and Cost request to determine if the treatment is a covered dental benefit. A Confirmation of Treatment and Cost is not a guarantee of payment. See the “Confirmation of Treatment and Cost” section for additional information. Limitations — Periodontal scaling/root planing is covered once per quadrant in a 36-month period from the date of service. — Limited occlusal adjustments are covered once in a 12-month period from the date of service. — Periodontal surgery (per site) is covered once in a three-year period from the date of service. o Periodontal surgery must be preceded by scaling and root planing done a minimum of six weeks and a maximum of six months prior to treatment, or the patient must have been in active supportive periodontal therapy. — Soft tissue grafts (two sites per quadrant) are covered once in a three-year period from the date of service. — Localized delivery of antimicrobial agents is a Covered Dental Benefit under certain conditions of oral health, such as periodontal Pocket depth readings of 5mm or greater.* 2024-01-03000-BB 13 LG PPOL 20240101