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<br />TYPE III PROCEDURES <br /> <br />MAJOR SERVICES <br /> <br />MAJOR RESTORATIONS <br />Inlays and onlays <br />Crowns and posts <br />- not covered for claimants prior to age 16 <br />Crown build-up, in conjunction with a crown <br />Cast post and core, in conjunction with a crown <br />Cast post, as part of a crown <br />- Inlays, onlays and crowns are covered only when needed due to substantial loss of tooth structure <br />caused by decay or accidental injury to teeth, which cannot be repaired by fIllings <br />- replacement of inlays, onlays and crowns is limited to one time in any eight years <br /> <br />ORAL SURGERY - ALVEOLAR OR GINGIVAL RECONSTRUCTION <br />Alveolectomy (with or without extractions) <br />Vestibuloplasty <br />Removal of exostosis of the maxilla or mandible <br />- includes removal of tori <br />Excision of hyperplastic tissue <br /> <br />PROSTHODONTICS - Fixed or Removable <br />Services to replace teeth extracted or accidentally lost while covered under, this Policy <br />- precision attachments, overdentures, specialized techniques and characterizations are not covered <br />Bridge abutments and pontics <br />- replacement is limited to one time in any eight consecutive years <br /> <br />Dentures <br /> <br />- includes adjustments, within six months of placement <br />- replacement is limited to once in any fIve consecutive years, per denture <br />- fees for partial dentures include all conventional clasps, rests and teeth <br />Complete denture - upper or lower <br />Partial denture - upper or lower <br />- acrylic base or predominantly base cast with acrylic saddles <br />Removable unilateral partial denture <br />- one piece, predominantly base casting, clasp attachments (including pontics) <br />Adjustments to dentures, more than six months after installation <br />Special tissue conditioning <br />- one per arch per calendar year <br />Reline of complete or partial denture <br />- once in any 36 consecutive months, per denture <br />Rebase of complete or partial denture <br />- once in any fIve consecutive years, per denture <br />Addition of teeth or c1asp(s) to existing partial denture to replace natural teeth extracted or accidentally lost while <br />covered under this Policy <br /> <br />GL11-DP.3 <br /> <br />35 <br /> <br />09/01/01 <br />