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TYPE II PROCEDURES (continued) <br />OATHOLOGY <br />Biopsy and examination of oral tissue <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 />EMERGENCY TREATMENT <br />Emergency examination and palliative 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 />- dry socket treatment <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 />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 />ENDODONTICS (treatment of diseases of root canal, periapical tissue and pulp chamber) <br />Pulpotomy <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 />OTHER BASIC SERVICES <br />Injection of antibiotics <br />- by the Dentist, in the Dentist's office <br />• <br />GL 11 -DP.2 <br />33 09/01/01 <br />