Page 28 - QCS.19 SPD - PPO

· Ensures unbiased review of the highest scientific standards by qualified individuals who
have no interest in the outcome of the review.
· The study or investigation takes place under an investigational new drug application reviewed by the U.S.
Food and Drug Administration.
· The study or investigation is a drug trial that is exempt from having such an investigational new drug
application.

· The clinical trial must have a written protocol that describes a scientifically sound study. It must have
been approved by all relevant institutional review boards (IRBs) before you are enrolled in the trial. We
may, at any time, request documentation about the trial.

· The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of
a Covered Health Care Service and is not otherwise excluded under the Policy.

Dental Services - Accident Only or Impacted Wisdom Teeth

Accident Only dental services when both of the following are true:
· Treatment is needed because of accidental damage;

· You receive dental services from a Doctor of Dental Surgery or Doctor of Medical Dentistry; and
· The accidental dental damage is severe enough that first contact with a Physician or dentist happened
within 72 hours of the accident. (You may request this time period be longer if you do so within 60 days of
the Injury and if extenuating circumstances exist due to the severity of the Injury.)
Please note that dental happens due to normal activities of daily living or extraordinary use of the teeth is not
considered an accident injury. Benefits are not available for repairs to teeth that are damaged due to such
activities.
Dental services to repair damage caused by accidental Injury must follow these timeframes:

· Treatment is started within three months of the accident, or if not a Covered Person at the time of the
accident, within the first three months of coverage under the Policy, unless extenuating circumstances
exist (such as prolonged hospitalization or the presence of fixation wires from fracture care); and

· Treatment must be completed within 12 months of the accident, or if not a Covered Person at the time of
the accident, within the first 12 months of coverage under the Policy.
Benefits for treatment of accidental Injury are limited to the following:

· Emergency examination;
· Diagnostic X-rays;

· Endodontic (root canal) treatment;
· Temporary splinting of teeth;

· Prefabricated post and core;
· Simple minimal restorative procedures (fillings);

· Extractions;
· Post–traumatic crowns if such are the only clinically acceptable treatment; or

· Replacement of lost teeth due to Injury with implant, dentures or bridges.

The Plan also covers dental care required for the direct treatment of an impacted wisdom tooth.

Page 23 Section 5- Additional Coverage Details
PPO - 2017