Section 2699.6205 - Excluded Dental Benefits(a) Dental benefits plans offered under this program shall exclude the following benefits: (1) Procedures, treatment or products which are not necessary for the patient's dental health. Procedures, treatments, or products are considered necessary for the patient's dental health if they are not investigational and are necessary because: (A) They are appropriate and are provided in accordance with accepted dental care standards in the state of California, and could not be omitted without adversely affecting the patient's condition or the quality of dental care rendered; and(B) If the proposed article or service is not commonly used, its application or proposed application has been preceded by a thorough review and application of conventional therapies; and(C) The service or article has been demonstrated to be of significantly greater therapeutic value than other, less expensive, services or articles.(2) Any procedure, service, product, treatment, or drug which is either:(A) Experimental or investigational or which is not recognized in accord with generally accepted dental care standards as being safe and effective for use in the treatment in question, or(B) Outmoded or not efficacious.(3) Treatment for any dental condition arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which benefits are provided or payable under any Worker's Compensation benefit plan.(4) Services related to acts of war, or needed while in the service of the armed forces of any country.(5) Treatments or services provided by persons other than licensed dentists or licensed dental professionals practicing under the supervision of a licensed dentist.(6) Dispensing of drugs which are not normally supplied in dental offices.(7) Hospital charges of any kind.(8) Treatment by any method of any condition of the temporomandibular joint.(9) Elective or cosmetic dentistry. This includes personalization or characterization of dentures, porcelain veneers on molar teeth, and tooth color restorations on molar teeth, but does not include porcelain veneers on other teeth and tooth color restorations on other teeth.(10) Oral surgery requiring the setting of fractures or dislocations.(11) Orthognathic surgery.(12) Removable orthodontic appliances, and fixed or removable orthodontic retainers, except as provided in the retention phase of the orthodontic benefit.(13) The replacement of fixed prosthodontics and removable prosthetic devices that are rendered nonfunctional due to patient abuse, misuse, or neglect.(14) Replacement of prosethetic devices such as full or partial dentures due to loss or theft.(15) General anesthesia, intravenously administered conscious sedation, or other conscious sedation including nitrous oxide.(16) Any procedure performed for the purpose of achieving full mouth occlusal equilibration to alter the bite.(17) Services or supplies solely to increase vertical dimension. These may include dentures, crowns, inlays and onlays, fixed bridges or any other appliance or service.(18) Services related to or treatment of malignancies, with the exception of biopsies.(19) Treatment of congenital malformations.(21) Supplies used for self-administered services or treatments which are related to dietary counseling, oral hygiene, plaque control, chemical analysis, or saliva.(22) Implants and the removal of implants are not covered benefits. However, if implants are determined to be less a costly alternative to a covered benefit by the dental carrier, they may be provided pursuant to Subsection 2699.6201(a)(10). Removal of an implant provided as a less costly alternative is a covered benefit. Replacement of an implant provided as a less costly alternative is limited to once every 60 consecutive months.(23) Restorations provided pursuant to Subsection 2699.6201(a)(2) utilizing gold, porcelain, and restorative materials other than amalgam or like materials are not covered benefits except as specified in Subsection 2699.6201(a)(2)(A)(1).(24) Grafting tissues from outside the mouth to tissue inside the mouth.(25) Services which are benefits under the medical insurance portion of the program.(26) For benefits received under fee-for-service dental benefit plans, all charges exceeding those considered usual, customary or reasonable.Cal. Code Regs. Tit. 10, § 2699.6205
1. Renumbering of former section 2699.6205 to section 2699.6103 and new section filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 5-23-94 order transmitted with amendment of subsection (a)(21) to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Amendment of subsection (a)(23) filed 10-18-95; operative 10-18-95 pursuant to Government Code section 11343.4(d) (Register 95, No. 42). Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
1. Renumbering of former section 2699.6205 to section 2699.6103 and new section filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 5-23-94 order transmitted with amendment of subsection (a)(21) to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Amendment of subsection (a)(23) filed 10-18-95; operative 10-18-95 pursuant to Government Code section 11343.4(d) (Register 95, No. 42).