What the SAIC Dental PPO Plan Does Not Cover

The SAIC Dental PPO Plan does not cover, or provide any payment for, the following:

• Services and supplies not necessary, as determined by Aetna, for the diagnosis, care or treatment of the disease or injury involved. This applies even if the service or supply is prescribed, recommended or approved by the person's attending physician or dentist;
• Care, treatment, services or supplies that are not prescribed, recommended and approved by the person's attending dentist;
• Initial bridges and dentures for the replacement of missing teeth, which were already missing prior to the effective date of coverage in SAIC's plan;
• Services or supplies that are determined by Aetna to be experimental or investigational. A drug, device, procedure or treatment will be determined to be experimental or investigational if:
  • Insufficient outcomes data is available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;
  • Approval has not been granted for marketing, if required by the Food and Drug Administration (www.fda.gov);
  • A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or
  • The written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental, investigational or for research purposes;
• Services of a resident physician or intern rendered in that capacity;
• Charges that are not reasonable, as determined by Aetna;
• Charges that are made only because there is health coverage;
• Charges that a covered person is not legally obliged to pay;
• Services and supplies that are furnished or paid for, or for which benefits are provided or required:
  • By reason of the past or present service of any person in the armed forces of a government; or
  • Under any law of a government (this does not include a plan established by a government for its own employees or their dependents or by Medicaid);
• Plastic surgery, reconstructive surgery, cosmetic surgery or other services and supplies which improve, alter or enhance appearance, whether or not for psychological or emotional reasons, except to the extent needed to repair an injury that occurs while the person is covered under this plan. Surgery must be performed:
  • In the calendar year of the accident that causes the injury; or
  • In the next calendar year; and
• Acupuncture therapy, including when it is:
  • Performed by a physician; and
• As a form of anesthesia in connection with surgery that is covered under this plan;.
• Orthodontic services and supplies for:
  • Retreatment
  • Changes in treatment required by an accident
  • Maxillofacial surgery
  • Myofunctional therapy
  • Treatment for cleft palate (unless for a child under 18)
  • Treatment of micrognathia (abnormal smallness of jaws) or macroglossia (congenital enlargement of tongue)
  • Treatment of primary or transitional dentition
  • Invisible braces
• Dental expense not specifically described in the plan.