CLM-2026-020306
Lakeside Skin Care Associates, Dermatology. Service 2025-11-24 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Mateo Sims
- Member ID
- UHC-98861-75
- Date of birth
- 1959-11-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426116
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9289
- Coverage period
- 2025-11-01 to present
- Deductible
- $24.08 of $1,000.002%
- Out-of-pocket maximum
- $193.73 of $2,000.0010%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 9796423611
- Location
- Tempe, AZ · TIN 98-6599721
- Authorisation / referral
- PA2025141270 / 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 | — | 1 | 1 | $2,404.00 | $1,322.20 | — | — | Review |
| Totals | $2,404.00 | $1,322.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-223437
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002002 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-24: MEDICARE-ADV-A (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025141270 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7921872736). | |
| 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 Skin Care Associates2025-11-24 14:09
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 system2026-01-07 05:30
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025141270_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-11-24 to 2026-02-22.
- Itemized billitemized_PA-223437.pdf5 pages
Itemised statement totalling $2404.00 across 1 line.
- Medical recordrecords_PA-223437.pdf4 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 13:43Medical 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 indicates a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 7e8c396c
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028214 | 2026-07-30 | Riverside Clinical Laboratories | $113.00 | Approved |
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 indicates a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy.
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.