Limitations and Exclusions

The Fund provides benefits only for necessary and appropriate services.

The Fund provides benefits for a covered dental service that is determined by our third-party administrator (Delta Dental of Massachusetts) to be necessary and appropriate to diagnose or treat your dental condition. To be necessary and appropriate, a service must be consistent with the prevention of oral disease or with the diagnosis and treatment, on (1) those teeth that are decayed or fractured, or (2) those teeth where supporting periodontium is weakened by disease, in accordance with standards of good dental practice and not solely for your convenience or the convenience of your dentist.

Delta Dental of Massachusetts determines what is necessary and appropriate based on a review of your dental records describing your condition and treatment. It may be determined that a service is not necessary and appropriate even if your dentist has furnished, prescribed, ordered, recommended or approved that service.

The Fund does not provide benefits for:

If the Plan booklet does not expressly provide for a benefit or service, such benefit or service shall not be covered under the plan. By way of example, your expenses will not be covered and no benefits will be paid by the Fund for:

  • dental treatment for which an alternate course of treatment is recommended based on materials and methods of treatment which cost the least and which meet generally accepted dental standards.You may be reimbursed only the benefit allowed on the procedures specified under this alternatecourse of treatment;
  • treatment for the dental condition known as temporomandibular joint (TMJ) syndrome;
  • dental treatment, including orthodontics, which commenced prior to the date on which the member or dependent became eligible for benefits or for dental treatment which continues after the date on which eligibility is terminated;
  • dental treatment which is meant primarily to change or improve your appearance (cosmetic);
  • restorations for reasons other than decay or fracture, such as erosion, abrasion, or attrition;
  • transplants or laminate veneers;
  • replacement of dentures, bridges, space maintainers or periodontal appliances due to theft, loss or breakage;
  • claims submitted to Delta Dental of Massachusetts more than one year from the date on which you received dental treatment;
  • charges for services received after your annual plan maximum has been reached, excluding eligible preventive and diagnostic services and periodontal scaling and root planing, and immediate and complete dentures;
  • repair of crown or fixed partial denture if less than 24 months after initial placement;
  • more than one periodontal surgical procedure per quadrant in a 36 month period;
  • any portion of your dental expenses which are payable under any other dental or medical plan. You must inform the MPE Unit at Delta Dental of Massachusetts if your family has another dental insurance plan. The Fund will coordinate your total benefits in those cases where another family member has their own dental insurance. When benefits are coordinated, your children’s primary insurance plan will be the plan of the parent whose birthday comes earlier in the calendar year;
  • treatment performed by anyone other than a duly licensed dentist, except services performed by a licensed dental hygienist or dental assistant under the supervision of a licensed dentist in accordance with state laws;
  • a dentist’s charge to you for any appointment which you miss;
  • dental treatment due to accidental bodily injuries in the course of employment, or due to sickness resulting from an occupational disease, for which the member or dependent is entitled to benefits under applicable Workers Compensation Law, occupational disease law, or similar legislation, except as mandated by law;
  • dental treatment performed in a hospital owned and operated by the United States Government, or performed elsewhere at the expense of the Federal Government;
  • any dental services and supplies for which you or your dependents are not required to pay or charges that would not have been made if no Fund coverage was available;
  • dental treatment received which is subject to stated time limitations if received more frequently than the stated time limitations allow, regardless of what coverage, if any, was in effect at the time of the original treatment;
  • travel time and related expenses;
  • dietary advice and instructions in dental hygiene including methods of tooth brushing, the use of dental floss, plaque control programs and caries susceptibility tests;
  • a service, supply or procedure to increase the height of teeth (increase vertical dimension) or restore occlusion;
  • services, supplies or appliances to stabilize teeth when required due to periodontal disease such as periodontal splinting.
  • dental treatment which is determined to be inappropriate per CAMBRA protocols based on your assessed risk of disease.

Please be advised that procedure codes are subject to change during the Plan Year.

  • Important Note: Some services indicate that they are a covered benefit only once during the stated period of time (e.g. a crown is payable once every 84 months.) If you have previously received any of these services, no benefits will be payable if you receive the same service again within the stated period of time – even if you were not a member of the Fund, and regardless of what coverage, if any, on the original treatment date. For example, if you had a crown on July 1, 2016, you will not be eligible for another crown on the same tooth until a 84 month period has elapsed (July 1, 2023). Again, this applies even if you were not a member of the Fund, and regardless of what coverage you may have had, if any, on July 1, 2016. To avoid unexpected costs you should discuss any treatment with your dentist and submit a pre-treatment estimate.