2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 90
(6)
Emergency palliative treatment.
(7)
Laboratory tests necessary for the diagnosis or treatment of a covered dental disorder, including, but not
limited to, bacteriologic cultures and pulp vitality tests.
Diagnostic cast for Covered Persons – once per 2-year period.
(8)
Class B-Basic Services:
(1) Dental x-rays not included in Class A Expenses.
(2)
Oral Surgery, except that which is covered under any medical plan.
(3)
Periodontic treatment (gum treatments).
(4)
Endodontic Treatment, including root canal therapy.
(5)
Extractions. This service includes local anesthesia and routine post-operative care.
(6)
Recementing bridges, crowns or onlays.
(7)
Fillings, excluding gold fillings.
(8)
General or local anesthesia upon demonstration of Medical Necessity.
(9)
Antibiotic drugs.
(10) Porcelain and stainless steel crowns used in the replacement of deciduous (primary) teeth.
(11) Repair or recementing of inlays, onlays, bridgework, crowns or dentures. Relining or rebasing of dentures
more than one year after installation of either the initial or the replacement denture. Limited to one relining or
rebasement in any 24 consecutive month period.
(12) Injections of antibiotic drugs and/or application of desensitizing medication.
Class C-Major Services:
(1) Gold restorations, including inlays, onlays and foil fillings. The cost of gold restorations in excess of the cost
for amalgam, synthetic porcelain or plastic materials will be included only when the teeth must be restored
with gold.
(2)
Installation of crowns
(3)
Installing precision attachments for removable dentures.
(4)
Installing partial, full or removable dentures to replace one or more natural teeth that were extracted while the
person was covered for this benefit. This service also includes all adjustments made during 6 months following
the installation.
(5)
Addition of clasp or rest to existing partial removable dentures.
(6)
Initial installation of fixed bridgework to replace one or more natural teeth.
(7)
Replacing an existing removable partial or full denture or fixed bridgework; adding teeth to an existing
removable partial denture; or adding teeth to existing bridgework to replace newly extracted natural teeth.
However, this will apply only if the existing denture or bridgework was installed at least 5 years prior to its
replacement and cannot currently be made serviceable.
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