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Old 11-14-2020, 05:28 PM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 840
Default Claim denied a second time

This time they are asking for the Provider to complete a UB04 - CMS 1405 Form. I haven't been able to find this online. The EOB says it MUST be the most current version.
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53 yr old female 5'7" 141 lbs. non-smoker conservative treatments failed
2007 fusion @ C4-6 peek cages, failed due to long term use of cox-2 inhibitor
2008 revised C4-6 donor bone, plate & screws
2009 fusion with Roi-C @ C3-4
2015 MRI & CT mjr ddd @ C6-7, segmental kyphosis at C7-T1, 2-level M6-C prosthesis by Dr. Clavel Barcelona Spain
2019 H.O. formed behind M6-C @ C6-7 left nerve rt & in spinal canal.
2020 Revision C6-7 to a cp-ESP prosthesis by Dr. Schmitz Dusseldorf Germany
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