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Services provided in connection with a cardiac rehabilitation program may be considered reasonable and necessary for up to 36 sessions, usually 3 sessions a week in a single 8-12 week period. Maintenance or exercise therapy is not covered.

Chiropractic Services Chiropractic services are limited to a maximum of $1,500 per participant during a calendar year. Only manipulative therapy services apply to the $1,500 maximum. Payments for x-rays or laboratory services are not applied toward this maximum.

Dental Services Dental services are not covered under the Plan except for the following:

Coverage is provided for dental care, treatment, dental surgery, and dental appliances made necessary by accidental bodily injury to sound and natural teeth (which are free from effects of impairment or disease) caused solely through external means. The accidental injury must have occurred while the participant is covered under the Plan or as a direct result of a disease covered by the Plan. Injury to teeth as a result of chewing or biting is not considered an accidental injury.

Coverage is provided for inpatient hospital services/supplies and associated anesthesia services for dental care and treatment and dental or oral surgery if the hospital stay is determined to be medically necessary by Intracorp.

Coverage is provided for outpatient hospital or ambulatory surgical facility services/supplies and associated anesthesia services for dental care if it is determined to be medically necessary by Blue Cross & Blue Shield.

Except as indicated above, benefits are not provided for dental services including, but not limited to, the following:

  • In-mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related fitting or adjustment services, whether or not the purpose of such services or supplies is to relieve pain

  • Extraction of wisdom teeth

  • Removal, repair, replacement, restoration, or reposition of teeth lost or damaged in the course of biting or chewing

  • Repair, replacement, or restoration of fillings, crowns, dentures, or bridgework

  • Periodontal treatment (i.e., gum disease)

  • Dental cleaning, in-mouth scaling, planning, or scraping

  • Myofunctional therapy (muscle training therapy or training to correct or control harmful habits)

  • Root canal therapy

  • Routine tooth removal

  • Any dental service or treatment not associated with an accidental injury or as a direct result of a disease covered by the Plan

  • TMJ, except to the extent coverage is specifically provided in this Plan Document


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