CLM-2026-011814
Meadow Physical Therapy, Physical Therapy. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Patricia Sandoval
- Member ID
- UHC-68939-94
- Date of birth
- 1992-08-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417472
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5647
- Coverage period
- 2025-11-01 to present
- Deductible
- $96.04 of $500.0019%
- Out-of-pocket maximum
- $539.19 of $1,500.0036%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 7506329862
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- PA2025146336 / none
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 | — | 2 | 1 | $4,716.00 | $2,122.20 | — | — | Review |
| Totals | $4,716.00 | $2,122.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-214113
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001897 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-15: MEDICARE-ADV-A (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025146336 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow Physical Therapy2025-12-15 13:10
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-06 03:08
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-06 09:51
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025146336_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-15 to 2026-03-15.
- Itemized billitemized_PA-214113.pdf3 pages
Itemised statement totalling $4716.00 across 1 line.
- Medical recordrecords_PA-214113.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 engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:15The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not document any acute findings or red-flag symptoms [N1], [N3]. The payer policy requires that advanced imaging with a routine examination diagnosis must be supported by failed conservative treatment or red-flag symptoms, which is not present in this case [R-clinical_edit]. Therefore, the service is not medically necessary per payer policy [CO50].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · c5b21b6b
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) and the clinical note does not document any acute findings or red-flag symptoms [N1], [N3]. The payer policy requires that advanced imaging with a routine examination diagnosis must be supported by failed conservative treatment or red-flag symptoms, which is not present in this case [R-clinical_edit]. Therefore, the service is not medically necessary per payer policy [CO50].
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.