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<br />TYPE n PROCEDURES (continued) <br /> <br />PATHOLOGY <br />Biopsy and examination of oral tissue <br /> <br />ADMINISTRATION OF ANESTHESIA <br />General anesthesia or I.V. sedation <br />- administered in the Dentist's offIce by the Dentist or other person licensed to administer anesthesia <br />payable in connection with a Necessary complex oral surgery procedure <br />payable when underlying medical condition, age or health factors render anesthesia medically <br />necessary <br />not covered when benefIts for the accompanying surgical procedure are not payable <br />not covered when administered due to patient anxiety <br />anesthesia for orthodontic procedures (or for procedures to treat craniomandibular or <br />temporomandibular joint disorders where required by state law) is not covered under this provision of <br />this Policy <br /> <br />EMffiRGENCYTREATMffiNT <br />Emergency examination and palIiative treatment <br />Palliative treatment is limited to: <br />opening and drainage of a tooth when no endodontics is to follow <br />- smoothing down a chipped tooth <br />- drysockettreatment <br />- pericoronitis treatment <br />- treatment for apthous ulcers <br />BenefIts for emergency treatment are payable only if services are rendered in order to relieve dental pain or <br />dental injury <br /> <br />CONSULTATIONS <br />Diagnostic services <br />- provided by a Dentist other than the Dentist providing any treatment <br />- payable if no other services are rendered <br /> <br />ENDODONTICS (treatment of diseases of root canal, periapical tissue and pulp chamber) <br />Pulpotomy <br /> <br />- primary teeth only <br />Root canal therapy <br />- permanent teeth only <br />- includes necessary x-rays and cultures <br />Apexification <br />Apicoectomy <br />Root amputation <br />Hemisection <br /> <br />OTHER BASIC SERVICES <br />Injection of antibiotics <br />- by the Dentist, in the Dentist's office <br /> <br />GL11-DP.2 <br /> <br />33 <br /> <br />09/01/01 <br />