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Exclusions and Limitations <br />Exclusions <br />1. Services performed by a general dentist or dentist whose practice is limited to providing Specialty <br />Care, not contracted with SafeGuard without prior approval by SafeGuard, (except for out of area <br />emergency services). <br />2. Any dental services, or appliances which are determined to be not reasonable and/or necessary <br />for maintaining or improving the member's dental health, as determined by the SafaGuard <br />Selected General Dentist. <br />3. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. <br />4. Dental procedures or services performed solely for cosmetic purposes or solely for appearance. <br />6. Orthognathic surgery. <br />6. Any inpatlentfoutpatient hospital charges of any kind including dentist and/or physician charges, <br />prescriptions or medications. <br />7. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or <br />damaged due to abuse, misuse,or neglect. <br />8. Treatment of malignancies, cysts, or neoplasms. <br />9. Procedures, appliances, or restorations whose main purpose Is to change the vertical dimension <br />of occlusion, correct congenital, developmental, or medically Induced dental disorders Including, <br />but not limited to treatment of myofunctional, myoskeletal, or temporomandlbular Joint disorders <br />unless otherwise specified as an orthodontic benefit on the Schedule of Benefits, <br />10. Dental implants and services associated with the placement of implants, prosthodontics <br />restoration of dental implants, and specialized implant maintenance services, <br />11. Precision attachments. <br />12. Dental procedures initiated prior to the member's eligibility under this Plan or started after the <br />member's termination from the Plan. <br />13. Dental services provided for or paid by a federal or state government agency or authority, political <br />subdivision, or other public program other then Medicaid or Medicare. <br />14. Dental services required while serving In the Armed Forces of any country or international <br />authority or relating to a declared or undeclared war or acta of war. <br />16. Services considered unnecessary or experimental in nature. <br />16. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits such <br />as thumb sucking and tongue thrusting. <br />17. Any dental procedure or treatment unable to be performed in the dental office due to the general <br />health or physical limitations of the member including, but not limited to physical or emotional <br />resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics. <br />0041 -D -SOB <br />25C-48 <br />EL's 2.15 <br />