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#1
11-14-2020, 06:28 PM
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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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54 yr old female 5'7" 147 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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