Dental Exclusions Underwritten by United of Omaha Life Insurance Company or Mutual of Omaha Insurance Company

Benefits are not payable:

• For any treatment, procedure or supply which is not identified as a covered service in the Schedule.
• For any treatment, procedure or supply which is considered an experimental or investigational device, treatment or procedure.
• For any treatment, procedure or supply which is not considered medically necessary or which is provided for patient convenience or to relieve anxiety.
• For a treatment, procedure or supply for which benefits are payable under any other group health or dental plan maintained or sponsored by the policyholder.
• Related to tests and laboratory exams, bacteriologic studies, caries susceptibility tests, pulp vitality tests, oral pathology laboratory, oral hygiene instruction, education or training, histopathologic examinations, diagnostic casts and photographs, the diagnosis or treatment of congenital malformations, magnetic resonance imaging and gnathological procedures, services, supplies or procedures related to orthognathic surgery, osteoplasties, osteotomies, LeFort procedures, maxillofacial prosthetics, vestibuloplasties, stomatoplasties, and any procedures related to the diagnosis or treatment of jaw fractures.
• Related to the diagnosis or treatment of temporomandibular disorders (TMD) and functional/myofunctional therapy except to the extent as may be required by applicable state law, or unless otherwise listed as a covered service in the schedule.
• Related to orthodontic treatment, including diagnostic procedures.
• Related to Cosmetic or Reconstructive Procedures.
• For procedures, restorations, devices, appliances or dentures to change vertical dimension, to alter occlusion or to replace tooth structure lost through attrition, erosion or abrasion including occlusal adjustment or equilibration.
• The replacement of lost dentures or the replacement of lost or broken appliances.
• Ror athletic mouth guards, bruxism appliances or any procedure related to such appliance , except as specifically covered as an orthodontic or TMD procedure.
• For precision attachments, connector bars, coping materials, overdentures, unilateral partial dentures and stress breakers.
• For drugs and medications whether or not they require a written prescription, or for analgesics oreuphoric drugs.
• For cast restorations, full or partial dentures and fixed bridgework for, which final impressions were taken before the date insurance began or after insurance ends.
• For treatment, procedures, or supplies which we determine are customarily performed in association with a more comprehensive dental procedure, including, but not limited to, local anesthesia, pulp capping (direct or indirect), insulating/cementing bases, periodontal splinting (permanent or provisional), temporary crowns, bridges, and dentures; or any minor associated gingival involvement when performed in conjunction with a cast restoration or fixed bridgework.
• For duplication of treatments, procedures or supplies, including, but not limited to, when an insured person transfers from the care of one provider to the care of another provider.
  • Which arise out of or in the course of employment for any employer or for which the insured person is paid benefits under any workers' compensation or occupational disease law, or receives any settlement from a worker's compensation carrier.
  • Treatments, procedures or supplies for which the insured person is not liable for payment, or which are provided or paid for by a state or federal government or its agencies.
  • Results, whether the insured person is sane or insane, from an intentionally self-inflicted injury or sickness;
  • Results from the insured person's participation in a riot or in the commission of a felony.
  • Results from an act of declared or undeclared war or armed aggression.
  • Is incurred while the insured person is on active duty or training in the Armed Forces, National Guard or Reserves of any state or country and for which any governmental body or its agencies are liable.
  • For any service associated with the evaluation, preparation, maintenance, placement or removal of implants or for any implant related prosthetic, including but not limited to crowns, bridges and dentures.
  • For any service rendered by a person who lives with you or is a member of your family (Your Spouse; or a child, brother, sister or parent of You or Your Spouse).