ANNEXURE F: Dental Exclusions

(with due regard to the Prescribed Minimum Benefits)

The cost of general dentistry performed in hospital

The cost of gold, metal or other inlays in a denture or crown

Fee for after-hours visits which the Fund considers as convenience visits

Bleaching of vital teeth

Unregistered items and items listed as "by agreement" or "not applicable" in the tariff code listing

Lingual orthodontic treatment

Services that deviate from the available guidelines of the Department of Health and which are deemed to be excluded from benefits after evaluation of the available information

Gum guards for sport purposes

Laboratory costs, which according to the Scheme’s norms and judgement, seem to be above the general cost claimed by other dental service providers and dental laboratories treating similar conditions

Services or procedures which are regarded by the Fund as cosmetic, when alternative functional services exist (in which case the benefit will be excluded entirely or in part and/or paid in accordance with the cost of such functional alternative service)

The cost of a written report compiled by a dental practitioner or specialist for which prior authorisation was not granted by the Scheme

Ant treatment listed below

  1. Any specialised treatment listed in the Scheme rules as requiring pre-authorisation where no pre-authorisation was obtained
  2. Orthodontic treatment for dependants older than 18 years
  3. Orthodontic procedures including retainers are limited to once in a lifetime
  4. Electrognathographic recordings and other such electronic analyses
  5. Metal base to full dentures, including the laboratory cost
  6. Soft base to new dentures
  7. Diagnostic dentures
  8. Pontics on second molars
  9. Provisional and emergency crowns and associated laboratory cost
  10. Ozone therapy
  11. Resin bonding for restorations charged as separate procedure
  12. Dental bleaching and porcelain veneers
  13. Laboratory fabricated crowns and root canal treatment on primary teeth
  14. Gingivectomies
  15. Periodontal flap surgery and tissue grafting
  16. Surgical tooth exposure for orthodontic reasons
    1. In-hospital surgical tooth exposure that was not pre-authorised as part of an orthodontic treatment plan
    2. Orthodontic re-treatment or unauthorised initial treatment commencing on an orthodontic treatment plan
    3. Orthognathic (jaw correction) surgery and related hospital cost
    4. Sinus Lift
    5. Bone augmentations
    6. Bone and other tissue regeneration procedures; Cost of bone regeneration material, (including laboratory costs)
    7. Multiple hospital admissions for extensive conservative (basic) dentistry in young children.
    8. Laboratory delivery fees
    9. Cost of Mineral Trioxide
    10. Cost of gold, precious metal, semi-precious metal and platinum foil
    11. In-hospital treatment for procedure not considered as invasive based on fear and anxiety in adults
    12. Surgery associated with dental implants – grafts etc
    13. In-hospital dental implants, dentectomies, and apicectomies
    14. Mouth guards and snoring appliances and the associated laboratory cost (including material)
    15. Oral hygiene instructions; PerioChip

Surgery associated with dental implants – grafts etc
In-hospital dental implants, dentectomies, and apisectomies
Mouth guards and snoring appliances and the associated laboratory cost (including material)
Oral hygiene instructions; perio chip