Additional procedures to construct new crown under existing partial denture framework

Application of desensitizing medicaments

Application of desensitizing resin for cervical and/ or root surface

Behavior management, for Dental Option 1 only

Bleaching of teeth

Broken retainers

Collection of cultures and specimens

Connector bar or stress breaker

Diagnostic casts or study models

Duplicate x-rays, for Dental Option 1 only

Endodontic endosseous implants, for Dental Option 1 only

Exfoliative cytology sample collection or brush biopsy, for Dental Option 1 only

Experimental or investigational services: experimental or investigational services as determined by Asuris dental policy, for Dental Option 1 only

Fees, Taxes, Interest

Gold foil restorations, for Dental Option 1 only

Hospitalizations for dentistry

House/extended care facility calls

Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis

Incision and drainage of abscess extraoral soft tissue, complicated or non-complicated

Indirect pulp capping Interim partial or complete dentures

Labial veneers

Local anesthesia, sterilization, and supplies billed as separate charges (these procedures are considered inclusive of billed procedures)

Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth, for Dental Option 1 only

Lost or stolen items Maxillofacial prosthetic procedures

Military service related conditions: Any condition resulting from military service in the armed forces of any country or any act of war (declared or undeclared)

Modification of removable prosthesis following implant surgery

Nitrous oxide, for Dental Option 1 only

Occlusal analysis and adjustments

Occlusal guards, for Dental Option 1 only

Oral hygiene instructions

Oral/facial photographic images

Orthodontic services, including craniomandibular orthopedic treatment: procedures for tooth movement, regardless of purpose, correction of malocclusion, preventive orthodontic procedures, and other orthodontic treatment

Pediatric dentures, for Dental Option 1 only

Pin retention in addition to restoration

Precision attachments

Prescription drugs, including take home prescription drugs, pre-medications, or supplies

Provisional splinting, for Dental Option 1 only

Pulp vitality tests

Radical resection of maxilla or mandible

Radiographic/surgical implant index

Removal of nonodontogenic cyst, tumor, or lesion

Replacement of lost, stolen, or broken dental appliances

Services and supplies provided by a family member: services and supplies provided to a member by an immediate family member

Services and supplies that are not Medically necessary: Services and supplies that are not medically necessary for the treatment of an illness, injury or physical disability

Services performed in a laboratory, for Dental Option 1 only

Surgical procedures for isolation of a tooth with rubber dam

Surgical stent, for Dental Option 1 only

Therapeutic drug injections

Third Party Coverage: Services and supplies for treatment of illness or injury for which a third party is responsible [e.g. automobile medical, personal injury protection (PIP), automobile no-fault, homeowner, commercial premises coverage or similar coverage

Tobacco ornutritional counseling for the control and prevention of oral disease

Tooth transplantation, for Dental Option 1 only

Travel and transportation expenses

Treatment of complications (post surgical); unusual circumstances

Treatment of simple or compound fractures of the mandible

Treatment of Temporomandibular Joint Dysfunction

Unspecified implant procedures