benefit_rules_90.json

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      "text": "A periodic oral evaluation is a payable benefit once in a six-month period. The six-month period starts from the date of the examination.",
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          "label": "d0140 - limited oral evaluation - problem focused",
          "claimValue": "D0140",
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      "conditionTemplateType": "MULTIPLE_SELECTION",
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      "displayName": "applicable service"
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          "label": "medical necessity",
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      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
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  "highlights": [
    {
      "text": "A limited oral evaluation for an evaluation limited to a specific oral health problem is payable.",
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      "text": "These services require documentation on the claim form or attached to the claim form which specifies the medical and dental necessity of the visit.",
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  "subtype": "Service Limitation",
  "complianceTag": "compliance"
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  "displayName": "IA-4 [L]",
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      "values": [
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          "_id": "http://claims-audit.ibm.com/procedure_code_d0170",
          "label": "d0170 - re-evaluation - limited, problem focused (established patient; not post-operative visit)",
          "claimValue": "D0170",
          "type": "SINGLE"
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
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          "label": "medical necessity",
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      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
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  "highlights": [
    {
      "text": "A limited re-evaluation is payable when necessary to assess the status of a previously existing condition that is not postoperative.",
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  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
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  "displayName": "IA-5 A [H]",
  "conditions": [
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      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "reference period - amount of time"
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          "_id": "http://claims-audit.ibm.com/procedure_code_d0145",
          "label": "d0145 - oral evaluation for a patient under three years of age and counseling with primary caregiver",
          "claimValue": "D0145",
          "type": "SINGLE"
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
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    {
      "value": "2",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxAge",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "member - max age"
    },
    {
      "value": "1",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxUnits",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "unit limitation - max"
    },
    {
      "value": {
        "_id": "http://claims-audit.ibm.com/month",
        "label": "month(s)",
        "type": "SINGLE"
      },
      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
      "conditionTemplateType": "SINGLE_SELECTION",
      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
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    {
      "text": "An oral evaluation for children under three years of age and counseling with the primary caregiver (D0145) is payable once every six months. ",
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  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
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  "displayName": "IA-6 A [H]",
  "conditions": [
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      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_comprehensive_periodontal_evaluation",
          "label": "comprehensive periodontal evaluation",
          "type": "GROUP"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "value": "3",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "reference period - amount of time"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/same_provider",
          "label": "same provider",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasBillingCommonality",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "billing commonality"
    },
    {
      "value": {
        "_id": "http://claims-audit.ibm.com/year",
        "label": "year(s)",
        "type": "SINGLE"
      },
      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
      "conditionTemplateType": "SINGLE_SELECTION",
      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
    },
    {
      "value": "1",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxUnits",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "unit limitation - max"
    }
  ],
  "highlights": [
    {
      "text": "A comprehensive periodontal evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years.",
      "html": "<fragment-part sequence-number=\"184\" fragment-sequence-number=\"162\" complete-sentence=\"A comprehensive periodontal evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years.\">A </fragment-part><fragment-part sequence-number=\"185\" fragment-sequence-number=\"162\" complete-sentence=\"A comprehensive periodontal evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years.\">comprehensive periodontal evaluation </fragment-part><fragment-part sequence-number=\"186\" fragment-sequence-number=\"162\" complete-sentence=\"A comprehensive periodontal evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years.\">is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years.</fragment-part>",
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  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",    
  "complianceTag": "compliance"
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          "label": "d0150 - comprehensive oral evaluation - new or established patient",
          "claimValue": "D0150",
          "type": "SINGLE"
        },
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d0120",
          "label": "d0120 - periodic oral evaluation - established patient",
          "claimValue": "D0120",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMutuallyExclusiveReimbursableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "mutual exclusive reimbursable service"
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          "_id": "http://claims-audit.ibm.com/same_provider",
          "label": "same provider",
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasBillingCommonality",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "billing commonality"
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      "value": "1",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "reference period - amount of time"
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      "value": {
        "_id": "http://claims-audit.ibm.com/day",
        "label": "day(s)",
        "type": "SINGLE"
      },
      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
      "conditionTemplateType": "SINGLE_SELECTION",
      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
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    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_comprehensive_periodontal_evaluation",
          "label": "comprehensive periodontal evaluation",
          "type": "GROUP"
        }
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      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "mutual exclusive non-reimbursable service"
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  "highlights": [
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      "text": "A comprehensive periodontal evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the practice during the three years. It is not payable when provided with, or subsequent to, a comprehensive or periodic evaluation.",
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          "label": "d0321 - other temporomandibular joint films, by report",
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      "text": "Cone beam images for placement of dental implants are covered only when prior authorization for implants has been obtained.",
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      "displayName": "requirement - needed"
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  ],
  "highlights": [
    {
      "text": "c. Pulp Vitality Tests Pulp vitality testing includes multiple teeth and contra lateral comparisons and is payable when necessary for diagnosis.",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-656\"><fragment-part sequence-number=\"223\" fragment-sequence-number=\"199\" complete-sentence=\"c. Pulp Vitality Tests\">c. Pulp Vitality Tests </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-656\"><fragment-part sequence-number=\"224\" fragment-sequence-number=\"200\" complete-sentence=\"Pulp vitality testing includes multiple teeth and contra lateral comparisons and is payable when necessary for diagnosis.\">Pulp vitality testing includes <span class=\"mark\">multiple teeth an</span>d contra lateral comparisons and is payable when necessary for diagnosis.</fragment-part></div>",
      "serialization": "type:textContent|11349$11493$$mark$fragments",
      "beginFragmentSequenceNumber": 199,
      "endFragmentSequenceNumber": 200
    }
  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d161e32863fb10007015125"
  },
  "displayName": "IA-17 [L]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d0470",
          "label": "d0470 - diagnostic casts",
          "claimValue": "D0470",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/medical_necessity",
          "label": "medical necessity",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
    }
  ],
  "highlights": [
    {
      "text": "d. Casts Diagnostic casts are payable for orthodontic cases, implants or when requested by the IME. ",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-917\"><fragment-part sequence-number=\"225\" fragment-sequence-number=\"201\" complete-sentence=\"d. Casts\">d. Casts </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-917\"><fragment-part sequence-number=\"226\" fragment-sequence-number=\"202\" complete-sentence=\"Diagnostic casts are payable for orthodontic cases, implants or when requested by the IME.\">Diagnostic casts are payable for orthodontic cases, implants or when requested by the IME. </fragment-part></div>",
      "serialization": "type:textContent|11495$11595$$mark$fragments",
      "beginFragmentSequenceNumber": 201,
      "endFragmentSequenceNumber": 202
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d16203e863fb10007015128"
  },
  "displayName": "IA-18 [H]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_oral_prophylaxis",
          "label": "oral prophylaxis",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "value": "1",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxUnits",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "unit limitation - max"
    },
    {
      "value": "6",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "reference period - amount of time"
    },
    {
      "value": {
        "_id": "http://claims-audit.ibm.com/month",
        "label": "month(s)",
        "type": "SINGLE"
      },
      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
      "conditionTemplateType": "SINGLE_SELECTION",
      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/umls_disease_or_syndrome_mental_disability",
          "label": "mental disability",
          "type": "SINGLE",
          "claimValue": null
        },
        {
          "_id": "http://claims-audit.ibm.com/umls_disease_or_syndrome_physical_disability",
          "label": "physical disability",
          "type": "SINGLE",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasNoMedicalHistoryOfDisease",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue"
    }
  ],
  "highlights": [
    {
      "text": "Oral prophylaxis, including necessary scaling and polishing, is payable only once in a six-month period, except for members who need more frequent care because of a physical or mental condition (including members receiving orthodontic treatment). ",
      "html": "Oral prophylaxis, including necessary scaling and polishing, is payable only once in a six-month period, except for members who need more frequent care because of a <span class=\"mark\">physical or mental condition</span> (including members receiving orthodontic treatment). ",
      "serialization": "type:textContent|11747$11994$$mark$fragments",
      "beginFragmentSequenceNumber": 206,
      "endFragmentSequenceNumber": 206
    },
    {
      "text": "Electronic claims should be billed with \"DIS\" in the appropriate segment. ",
      "html": "E<span class=\"mark\">lectronic claims should be billed wi</span>th \"DIS\" in the appropriate segment. ",
      "serialization": "type:textContent|12092$12166$$mark$fragments",
      "beginFragmentSequenceNumber": 208,
      "endFragmentSequenceNumber": 208
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d1627e8863fb1000701512e"
  },
  "displayName": "IA-19 [H]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_topical_fluoride_treatments",
          "label": "topical fluoride treatments",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "value": "1",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxUnits",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "unit limitation - max"
    },
    {
      "value": "90",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "reference period - amount of time"
    },
    {
      "value": {
        "_id": "http://claims-audit.ibm.com/day",
        "label": "day(s)",
        "type": "SINGLE"
      },
      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
      "conditionTemplateType": "SINGLE_SELECTION",
      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_fluoride_prophylaxis_paste",
          "label": "fluoride prophylaxis paste",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasExcludedService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "excluded service"
    }
  ],
  "highlights": [
    {
      "text": "b. Fluoride Topical application of fluoride (gel, mouth rinse) is payable once every 90 days. (This does not include the use of fluoride prophylaxis paste as fluoride treatment.) ",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-1067\"><fragment-part sequence-number=\"245\" fragment-sequence-number=\"220\" complete-sentence=\"b. Fluoride\">b. Fluoride </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1067\"><fragment-part sequence-number=\"246\" fragment-sequence-number=\"221\" complete-sentence=\"Topical application of fluoride (gel, mouth rinse) is payable once every 90 days.\">Topical application of fluoride (gel, mouth rinse) is payable once every 90 days. </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1067\"><fragment-part sequence-number=\"247\" fragment-sequence-number=\"222\" complete-sentence=\"(This does not include the use of fluoride prophylaxis paste as fluoride treatment.)\">(This does not include the use of fluoride prophylaxis paste as fluoride treatment.) </fragment-part></div>",
      "serialization": "type:textContent|12306$12485$$mark$fragments",
      "beginFragmentSequenceNumber": 220,
      "endFragmentSequenceNumber": 222
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d162a5a863fb10007015132"
  },
  "displayName": "IA-20 A [M]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d1351",
          "label": "d1351 - sealant - per tooth",
          "type": "SINGLE",
          "claimValue": "D1351"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/permanent_posterior_teeth",
          "label": "permanent posterior teeth",
          "type": "GROUP",
          "claimValue": null
        },
        {
          "_id": "http://claims-audit.ibm.com/primary_posterior_teeth",
          "label": "primary posterior teeth",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasPerBodyPartApplicability",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "body part"
    },
    {
      "value": "18",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMaxAge",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "member - max age"
    },
    {
      "value": "0",
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "member - min age"
    }
  ],
  "highlights": [
    {
      "text": "c. Pit and Fissure Sealants Pit and fissure sealants are payable for placement on deciduous and permanent posterior teeth only. Reimbursement for sealants is restricted to work performed on children through 18 years of age and for persons who have a physical or mental disability that impairs their ability to maintain adequate oral hygiene. ",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-1120\"><fragment-part sequence-number=\"248\" fragment-sequence-number=\"223\" complete-sentence=\"c. Pit and Fissure Sealants\">c. Pit and Fissure Sealants </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1120\"><fragment-part sequence-number=\"249\" fragment-sequence-number=\"224\" complete-sentence=\"Pit and fissure sealants are payable for placement on deciduous and permanent posterior teeth only.\">Pit and fissure sealants are payable for placement on <span class=\"mark\">deciduous</span> and permanent posterior teeth only. </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1120\"><fragment-part sequence-number=\"250\" fragment-sequence-number=\"225\" complete-sentence=\"Reimbursement for sealants is restricted to work performed on children through 18 years of age and for persons who have a physical or mental disability that impairs their ability to maintain adequate oral hygiene.\">Reimbursement for sealants is restricted to work performed on children through 18 years of age and for persons who have a physical or mental disability that impairs their ability to maintain adequate oral hygiene. </fragment-part></div>",
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      "beginFragmentSequenceNumber": 223,
      "endFragmentSequenceNumber": 225
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d162ba3863fb10007015136"
  },
  "displayName": "IA-20 B [M]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d1351",
          "label": "d1351 - sealant - per tooth",
          "type": "SINGLE",
          "claimValue": "D1351"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/permanent_posterior_teeth",
          "label": "permanent posterior teeth",
          "type": "GROUP",
          "claimValue": null
        },
        {
          "_id": "http://claims-audit.ibm.com/primary_posterior_teeth",
          "label": "primary posterior teeth",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasPerBodyPartApplicability",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "body part"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/umls_disease_or_syndrome_mental_disability",
          "label": "mental disability",
          "type": "SINGLE",
          "claimValue": null
        },
        {
          "_id": "http://claims-audit.ibm.com/umls_disease_or_syndrome_physical_disability",
          "label": "physical disability",
          "type": "SINGLE",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMedicalHistoryOfDisease",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "member - medical history of disease"
    }
  ],
  "highlights": [
    {
      "text": "c. Pit and Fissure Sealants Pit and fissure sealants are payable for placement on deciduous and permanent posterior teeth only. Reimbursement for sealants is restricted to work performed on children through 18 years of age and for persons who have a physical or mental disability that impairs their ability to maintain adequate oral hygiene. ",
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      "serialization": "type:textContent|12486$12828$$mark$fragments",
      "beginFragmentSequenceNumber": 223,
      "endFragmentSequenceNumber": 225
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d162ca1863fb1000701513a"
  },
  "displayName": "IA-21 [L]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/medical_necessity",
          "label": "medical necessity",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d1353",
          "label": "d1353 - sealant repair - per tooth",
          "claimValue": "D1353",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    }
  ],
  "highlights": [
    {
      "text": "Replacement sealants are covered when medically necessary. Documentation in the member record must indicate that the sealant is totally or partially missing. ",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-1314\"><fragment-part sequence-number=\"251\" fragment-sequence-number=\"226\" complete-sentence=\"Replacement sealants are covered when medically necessary.\">Replacement sealants are covered when medically necessary. </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1314\"><fragment-part sequence-number=\"252\" fragment-sequence-number=\"227\" complete-sentence=\"Documentation in the member record must indicate that the sealant is totally or partially missing.\">Documentation in the member record must indicate that the sealant is totally or partially missing. </fragment-part></div>",
      "serialization": "type:textContent|12828$12986$$mark$fragments",
      "beginFragmentSequenceNumber": 226,
      "endFragmentSequenceNumber": 227
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d162d91863fb1000701513d"
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  "displayName": "IA-22 [L]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/prior_authorization_requirement",
          "label": "prior authorization requirement (par)",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasNoRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - not needed"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_space_management_services",
          "label": "space management services",
          "type": "GROUP"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/medical_necessity",
          "label": "medical necessity",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
    }
  ],
  "highlights": [
    {
      "text": "d. Space Management Services Space management services do not require prior authorization. They are payable when: • Premature loss of teeth would permit existing teeth to shift causing a handicapping malocclusion, or • There is too little dental ridge to accommodate either the number or the size of teeth and significant dental disease will result if not corrected. ",
      "html": "<div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"253\" fragment-sequence-number=\"228\" complete-sentence=\"d. Space Management Services\">d. Space Management Services </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"254\" fragment-sequence-number=\"229\" complete-sentence=\"Space management services do not require prior authorization.\">Space management services do not require prior authorization. </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"255\" fragment-sequence-number=\"230\" complete-sentence=\"They are payable when:\">They are payable when: </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"256\" fragment-sequence-number=\"231\" complete-sentence=\"•\">• </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"257\" fragment-sequence-number=\"232\" complete-sentence=\"Premature loss of teeth would permit existing teeth to shift causing a handicapping malocclusion, or\">Premature loss of teeth would permit existing teeth to shift causing a handicapping malocclusion, or </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"258\" fragment-sequence-number=\"233\" complete-sentence=\"•\">• </fragment-part></div><div class=\"BenefitRuleTextHighlighter-fragment-1364\"><fragment-part sequence-number=\"259\" fragment-sequence-number=\"234\" complete-sentence=\"There is too little dental ridge to accommodate either the number or the size of teeth and significant dental disease will result if not corrected.\">There is too little dental ridge to accommodate either the number or the size of teeth and significant dental disease will result if not corrected. </fragment-part></div>",
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  "_class": "BenefitRule",
  "subtype": "Service Limitation",
  "complianceTag": "compliance"
},{
  "_id": {
    "$oid": "5d162f6d863fb10007015140"
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  "displayName": "IA-23 [H]",
  "conditions": [
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_fixed_space_maintainer_placement",
          "label": "fixed space maintainer placement",
          "type": "GROUP",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMutuallyExclusiveReimbursableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "mutual exclusive reimbursable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/same_provider",
          "label": "same provider",
          "type": "SINGLE",
          "claimValue": null
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasBillingCommonality",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "billing commonality"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d1555",
          "label": "d1555 - removal of fixed space maintainer",
          "claimValue": "D1555",
          "type": "SINGLE"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasMutuallyExclusiveNotReimbursableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "mutual exclusive non-reimbursable service"
    }
  ],
  "highlights": [
    {
      "text": "Removal of a fixed space maintainer is payable when performed by a dentist or practice that did not originally provide the appliance. ",
      "html": "Removal of a fixed space maintainer is payable when performed by a dentist or practice that did not originally provide the appliance. ",
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      "beginFragmentSequenceNumber": 235,
      "endFragmentSequenceNumber": 235
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  ],
  "policyId": "5c8a6c8f3a25490006d6a146",
  "status": "VERIFIED",
  "_class": "BenefitRule",
  "subtype": "Mutually Exclusive",
  "complianceTag": "non compliance"
},{
  "_id": {
    "$oid": "5d16310e863fb10007015144"
  },
  "displayName": "IA-24 [H]",
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    {
      "text": "Prefabricated stainless steel crowns with a resin window are covered for anterior teeth only. ",
      "html": "<fragment-part sequence-number=\"331\" fragment-sequence-number=\"303\" complete-sentence=\"Prefabricated stainless steel crowns with a resin window are covered for anterior teeth only.\">Prefabricated stainless steel crowns </fragment-part><fragment-part sequence-number=\"332\" fragment-sequence-number=\"303\" complete-sentence=\"Prefabricated stainless steel crowns with a resin window are covered for anterior teeth only.\">with a resin window are covered for anterior teeth only. </fragment-part>",
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      "conditionTemplateType": "FREE_TEXT",
      "_class": "FreeTextConditionTemplateValue",
      "displayName": "unit limitation - max"
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  "highlights": [
    {
      "text": "Esthetic coated stainless steel crowns are covered only on primary anterior teeth numbers C through H and M through R. One crown per each primary anterior tooth is allowed. Prior authorization is not required. ",
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      "_class": "MultipleSelectionConditionTemplateValue",
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    {
      "text": "All laboratory-fabricated crowns utilizing non-precious materials require prior authorization. Approval shall be granted when: • Coronal loss of tooth structure does not allow restoration with a composite or amalgam restoration, or • There is evidence of recurring decay surrounding a large existing restoration, or • The tooth is fractured or has a broken cusp, or • The tooth has had endodontic treatment. ",
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    {
      "text": "Crowns using noble metals are payable when the member meets the criteria for a crown and the member is allergic to all other restoration materials. Prior authorization is required. ",
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      "_class": "SingleSelectionConditionTemplateValue",
      "displayName": "reference period - unit of time"
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  ],
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    {
      "text": "A replacement crown for the same tooth in less than 18 months due to failure of the crown is not covered and is the responsibility of the dentist who originally placed the crown. ",
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
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      "conditionTemplateType": "MULTIPLE_SELECTION",
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      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "mutual exclusive reimbursable service"
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    {
      "text": "Restoration is not payable following a sedative filling in the same tooth, unless the sedative filling was placed more than 30 days previously. ",
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  "displayName": "IA-39 [L]",
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
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    {
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        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d2954",
          "label": "d2954 - prefabricated post and core in addition to crown",
          "claimValue": "D2954",
          "type": "SINGLE"
        },
        {
          "_id": "http://claims-audit.ibm.com/procedure_code_d2952",
          "label": "d2952 - post and core in addition to crown, indirectly fabricated",
          "claimValue": "D2952",
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        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    }
  ],
  "highlights": [
    {
      "text": "Cast post and core, post and composite, or post and amalgam, in addition to a crown, are a covered benefit when the tooth is functional and the integrity of the tooth would be jeopardized by no post support. ",
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      ],
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      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
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    {
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        {
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          "label": "medical necessity",
          "type": "SINGLE"
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
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  ],
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    {
      "text": "Crown repair is payable. For pricing purposes, documentation of the repair must be submitted with the claim. ",
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      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
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        {
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          "label": "medical necessity",
          "type": "SINGLE"
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      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasRequirement",
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      "_class": "MultipleSelectionConditionTemplateValue",
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    }
  ],
  "highlights": [
    {
      "text": "Unspecified restorative procedures require documentation of medical necessity submitted with the claim and may not be payable. ",
      "html": "Unspecified restorative procedures require documentation of medical necessity submitted with the claim and may not be payable. ",
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    "$oid": "5d1b79e7f57966000616f84b"
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      "values": [
        {
          "_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_root_canal",
          "label": "root canal",
          "type": "GROUP"
        }
      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "applicable service"
    },
    {
      "values": [
        {
          "_id": "http://claims-audit.ibm.com/prior_authorization_requirement",
          "label": "prior authorization requirement (par)",
          "type": "SINGLE"
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      ],
      "conditionTemplateId": "http://claims-audit.ibm.com/hasNoRequirement",
      "conditionTemplateType": "MULTIPLE_SELECTION",
      "_class": "MultipleSelectionConditionTemplateValue",
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    },
    {
      "values": [
        {
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          "label": "permanent posterior teeth",
          "type": "GROUP"
        },
        {
          "_id": "http://claims-audit.ibm.com/permanent_anterior_teeth",
          "label": "permanent anterior teeth",
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      "text": "Periodontal maintenance therapy requires prior approval and includes oral prophylaxis, measurement of pocket depths and limited root planing and scaling. This procedure may be approved once per three-month interval after periodontal scaling and root planing and periodontal surgical procedures have been provided as long as periodontal charting shows evidence of active periodontal disease (pocket depths of 4 mm or greater, inflammation or bleeding on probing). If pocket depths have returned to 3 mm or less, and there are no signs of active periodontal disease, quarterly prophylaxis should be provided instead. ",
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    "$oid": "5d1ca114f57966000616f872"
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          "_id": "http://claims-audit.ibm.com/procedure_code_d4910",
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      "_class": "FreeTextConditionTemplateValue",
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      "conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
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          "_id": "http://claims-audit.ibm.com/medical_necessity",
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      "text": "Periodontal maintenance therapy requires prior approval and includes oral prophylaxis, measurement of pocket depths and limited root planing and scaling. This procedure may be approved once per three-month interval after periodontal scaling and root planing and periodontal surgical procedures have been provided as long as periodontal charting shows evidence of active periodontal disease (pocket depths of 4 mm or greater, inflammation or bleeding on probing). If pocket depths have returned to 3 mm or less, and there are no signs of active periodontal disease, quarterly prophylaxis should be provided instead.",
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},{
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      "text": "Periodontal surgical procedures, including gingivectomy, osseous surgery, and osseous allograft, will be approved after: • Periodontal scaling and root planing has been provided, • A re-evaluation examination has been completed, and • The member has demonstrated reasonable oral hygiene, unless the member is unable to demonstrate reasonable oral hygiene because of physical or mental disability or demonstrate gingival hyperplasia resulting from drug therapy.",
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      "_class": "MultipleSelectionConditionTemplateValue",
      "displayName": "requirement - needed"
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    {
      "text": "Pedicle soft tissue graft and free soft tissue graft are payable services with prior approval and written narrative describing medical necessity.",
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    {
      "text": "Application of a desensitizing medicament is payable on a per visit basis for tooth or root sensitivity. ",
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      "text": "Application of a desensitizing medicament ",
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      "beginFragmentSequenceNumber": 633,
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    {
      "text": "It is not payable when bases, liners, or adhesives are to be used under a restoration. ",
      "html": "It is not payable when bases, liners, or adhesives are to be used under a restoration. ",
      "serialization": "type:textContent|36488$36575$$mark$fragments",
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