Page 95

Effective Date:

Approval Date: 95

Section 5 – Services Not Covered The following is a list of services that are not payable under the Iowa hawk-i Dental Plan. Please Note: Even if a service is not specifically listed as an exclusion, it may not be covered under this plan. Contact the dental carrier if you are unsure a certain service is covered. Services Not Covered D0320 TMJ arthrogram D0321 Other TMJ films D0322 Tomographic survey D0360 Cone Beam CT D0362 Cone Beam multiple images 2 dim. D0363 Cone Beam multiple images 3 dim. D0416 Viral culture D0418 Analysis of saliva example chemical or biological analysis of saliva for disagnostic purposes. D0425 Caries test D0431 Adjunctive pre-diagnostic test D0475 Declassification procedure D0476 Special stains for microorganisms D0477 Special stains not for microorganisms D0478 Immunohistochemical stains D0479 Tissue in-situ-hybridization D0481 Electron microscopy D0482 Direct immunofluorescence D0483 In-direct immunofluorescence D0484 Consultation on slides prepared elsewhere D0485 Consultation including preparation of slides D0486 Brush biopsy sample D1310 Nutritional counseling D1320 Tobacco counseling D1330 Oral Hygiene Instruction D1555 Removal of fixed space maintainer D7292 Surgical replacement screw retained D7293 Surgical replacement w/surgical flap D7294 Surgical replacement without the surgical flap D7880 TMJ Appliance D7899 TMJ Therapy D7997 Appliance Removal D7998 Intraoral placement of a fixation device D2410 Gold Foil 1 surface D2420 Gold Foil 2 surface D2430 Gold Foil 3 surface D2799 Provisional Crown D2955 Post Removal D2970 Temporary Crown D2975 Coping D3460 Endodontic Implant