Claim CLM-2024-8791

Patient

Name: Dante Russo
Date of birth: 1971-01-28
Patient id: H005

Payer

Name: Humana
Payer id code: 61101

Provider

Name: Northside Medical
NPI: 1982744321

Service

Date of service: Apr 7 (denial date, no service date on file)
Procedure: 70553, MRI Lumbar Spine
Diagnosis code: G43.909
Billed amount: $4,200

Denial

Reason: Not Covered, code 96
Date: Apr 7

Appeal

Status: approved
Tracking id: APP-2024-1085
Submitted: Apr 10

Prepared by Heron on Aug 30.