— Intravenous sedation is covered in conjunction with covered endodontic, periodontic and oral surgery procedures, as determined by DDWA. — Either general anesthesia or intravenous sedation (but not both) are covered when performed on the same day. — Sedation, which is either general anesthesia or intravenous sedation, is a Covered Dental Benefit only once per day. Exclusions — General anesthesia or intravenous sedation for routine post-operative procedures is not a paid covered benefit except as described above for children through the age of six or physically or developmentally disabled person. Class II Palliative Treatment Covered Dental Benefits — Palliative treatment for pain Limitations — Postoperative care and treatment of routine post-surgical complications are included in the initial cost for surgical treatment if performed within 30 days. — Palliative treatment is not a paid covered benefit when the same provider performs any other definitive treatment on the same date Class II Restorative Covered Dental Benefits — Restorations (fillings) — Stainless steel crowns or prefabricated crowns — Refer to “Class III Restorative” if teeth are restored with crowns, inlays, veneers, or onlays. Limitations — Restorations on the same surface(s) of the same tooth are covered once in a two-year period from the date of service for the following reasons: o Treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) o Fracture resulting in significant loss of tooth structure (missing cusp) o Fracture resulting in significant damage to an existing restoration — If a resin-based composite or glass ionomer restoration is placed in a posterior tooth (except those placed in the buccal (facial) surface of bicuspids), it will be considered an elective procedure and an amalgam allowance will be made, with any difference in cost being the responsibility of the patient. — Stainless steel crowns or prefabricated crowns are covered once in a two-year period from the seat date. — Restorations placed on the same tooth within two months of the application of Caries arresting medicament are Not a Paid Covered Dental Benefit. Exclusions — Overhang removal — Copings — Re-contouring or polishing of restoration — Restorations necessary to correct vertical dimension or to alter the morphology (shape) or occlusion 2024-01-03000-BB 12 LG PPOL 20240101