California Code of Regulations
Title 10 - Investment
Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California)
Article 3 - Benefits
Section 2699.6205 - Excluded Dental Benefits
Universal Citation: 10 CA Code of Regs 2699.6205
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(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.
(20) Tooth
replantation.
(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.
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.
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