CLM-2026-010929
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Donna Castro
- Member ID
- UHC-02435-42
- Date of birth
- 1939-11-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408547
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9902
- Coverage period
- 2025-01-01 to 2026-05-28
- Deductible
- $1,139.22 of $1,500.0076%
- Out-of-pocket maximum
- $1,485.60 of $3,000.0050%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 5430748827
- Location
- Denver, CO · TIN 22-9016721
- Authorisation / referral
- PA2025072790 / REF110639
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,259.00 | $1,792.45 | — | — | Review |
| Totals | $3,259.00 | $1,792.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-705107
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006368 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: CORE-HMO (HMO), effective 2025-01-01, terms 2026-05-28. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025072790 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Internal Medicine Associates (8566398227). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-01-12 16:16
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-21 04:28
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-21 17:57
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025072790_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-12 to 2026-04-12.
- Itemized billitemized_PA-705107.pdf9 pages
Itemised statement totalling $3259.00 across 1 line.
- Medical recordrecords_PA-705107.pdf16 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-23 19:19The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings [N1]. The clinical note does not document any acute findings, red-flag symptoms, or failed conservative treatment, which are required for advanced imaging to be considered medically necessary under the payer policy [N3]. Therefore, the service is not medically necessary per payer policy [R-clinical_edit].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 9522342f
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings [N1]. The clinical note does not document any acute findings, red-flag symptoms, or failed conservative treatment, which are required for advanced imaging to be considered medically necessary under the payer policy [N3]. Therefore, the service is not medically necessary per payer policy [R-clinical_edit].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.