TDP Non-Covered Services, Supplies and Charges
The following comprehensive list of exclusions is provided courtesy of TRICARE.
- Any dental service or treatment not specifically listed as a covered service.
- Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, MetLife will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law.
- Those submitted by a dentist that are for the same services performed on the same date for the same member by another dentist.
- Those that are experimental or investigative (deemed unproven).
- Those that are for any illness or bodily injury that occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any government unit. This exclusion applies whether or not the beneficiary claims the benefits or compensation.
- Those that are later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law.
- Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law.
- Those for which the patient would have no obligation to pay in the absence of this or any similar coverage.
- Those received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.
- Those performed prior to the patient's effective coverage date.
- Those incurred after the termination date of the patient's coverage, unless otherwise indicated.
- Those that are not medically or dentally necessary or that are not recommended or approved by the treating dentist. Note: Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the patient by a network dentist unless the dentist notifies the patient of his or her liability prior to treatment and the patient chooses to receive the treatment. Network dentists should document such notification in their records.
- Those not meeting accepted standards of dental practice.
- Those that are for unusual procedures and techniques.
- Those performed by a dentist who is compensated by a facility for similar covered services performed for beneficiaries.
- Those resulting from the patient's failure to comply with professionally prescribed treatment.
- Telephone consultations.
- Any charges for failure to keep a scheduled appointment.
- Any services that are strictly cosmetic in nature, including, but not limited to, charges for personalization or characterization of prosthetic appliances.
- Duplicate and temporary devices, appliances, and services.
- Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD).
- Plaque-control programs, oral hygiene instruction, and dietary instructions.
- Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full-mouth rehabilitation, and restoration for misalignment of teeth.
- Restorations that are placed for cosmetic purposes only.
- Gold foil restorations.
- Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan.
- Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient).
- Adjunctive dental services as defined by applicable federal regulations.
- Charges for copies of members' records, charts, or X-rays, or any costs associated with forwarding/mailing copies of members' records, charts, or X-rays.
- Nitrous oxide.
- Oral sedation.
- State or territorial taxes on dental services performed.
Certain services and treatments are not covered by the TRICARE Dental Program because they're often covered by TRICARE's medical coverage. These treatments and services are called "adjunctive services."
So what exactly is an adjunctive service? According to TRICARE, adjunctive dental care is dental care that is:
- Medically necessary in the treatment of an otherwise-covered medical (not dental) condition.
- An integral part of the treatment of such medical condition.
- Essential to the control of the primary medical condition.
- Required in preparation for, or as the result of, dental trauma, which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).
According to TRICARE, the following diagnoses or conditions may be covered under your medical insurance and are not covered by the TRICARE Dental Program, even if the services are provided by a general dentist or oral surgeon:
- Treatment for relief of myofascial pain dysfunction syndrome or TMD.
- Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for, or as a result of, trauma to teeth and supporting structures caused by medically necessary treatment of an injury or disease.
- Procedures associated with preventative and restorative dental care when associated with radiation therapy to the head or neck, unless otherwise covered as a routine preventative procedure under this plan.
- Total or complete ankyloglossia (a condition where the bottom of the tongue is attached to the floor of the mouth).
- Intraoral abscesses that extend beyond the dental alveolus.
- Extraoral abscesses.
- Cellulitis and osteitis that is clearly exacerbating and directly affecting a medical condition currently under treatment.
- Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an accidental injury.
- Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues associated with traumatic injury (such as a gunshot wound), in addition to services related to treating neoplasms or iatrogenic dental trauma.
If you have questions about whether or not a service or treatment is covered by the TRICARE Dental Plan, please contact MetLife through one of the options listed below:
- CONUS Phone Number: 1-855-638-8371
- OCONUS Phone Number: 1-855-638-8372
- TDD/TTY: 1-855-638-8373
- Web Site: MetLife Online