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 that the Scheme 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 that are deemed to be excluded from benefits after evaluation of the available information
  • Gum guards for sport purposes
  • Laboratory costs that, according to the Scheme’s norms and judgement, seem to be above the general cost claimed by other dental service providers and laboratories treating similar conditions
  • Services or procedures that are regarded by the Scheme 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

 

Any 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 old
  3. Orthodontic procedures, including retainers, are limited to once in a lifetime
  4. Electrognathographic recordings and other such electronic analysis
  5. Metal base to full dentures, including the laboratory cost
  6. Soft base to new dentures
  7. Diagnostic dentures
  8. Pontic on third 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. i. surgical tooth exposure for orthodontic reason in hospital
    ii. surgical tooth exposure that was not pre-authorised as part of an orthodontic treatment plan
    iii. orthodontic re-treatment or unauthorised initial treatment commencing on an orthodontic treatment plan
    iv. orthognathic (jaw correction) surgery and related hospital costs
    v. sinus lift
    vi. bone augmentation
    vii. bone and other tissue regeneration procedures; cost of bone regeneration material (including laboratory costs)
    viii. multiple hospital admissions for extensive conservative (basic) dentistry in young children (only one admission per  child every 24 months)
    ix. laboratory delivery fees
    x. cost of mineral trioxide
    xi. cost of gold, precious metal, semi-precious metal and platinum foil
    xii. in-hospital treatment for procedure not considered as invasive based on fear and anxiety in adults
    xiii. surgery associated with dental implants, grafts, etc.
    xiv. in-hospital dental implants, dentectomies, and apicectomies
    xv. mouth guards and snoring appliances and the associated laboratory cost (including material)
    xvi. oral hygiene instructions; PerioChip