Adverse determination — denied

Prior Authorization Decision Letter

Synthetic adverse determination specimen for DeskGate v2.6.8 offline simulation. Zero live PHI.

Decision:	Denied
Tracking / Auth Reference:	BCBS-TN-PA-88429117
Member / Subscriber ID:	SYN-884291-Q
Patient Name:	Vargas, Elena M.
Date of Birth:	04/12/1979
Requested CPT / HCPCS:	97110 x12, 97530 x8
Primary diagnosis:	M17.11
Denial code:	UM-PA-14
Policy:	Outpatient Rehabilitation Medical Policy ORT-PT-2026 §4.2 — failed conservative therapy must be dated in the attached note

Reason for denial: Insufficient documentation of failed conservative therapy duration. The submitted packet did not include dated trial notes for oral NSAID discontinuation or the May 2026 intra-articular injection.

Missing / additional documentation requested:

Dated NSAID trial (agent, dose, weeks, reason discontinued); corticosteroid injection date and duration of relief; signed PT order listing unit counts.

Appeal window: 180 days from this letter. Reconsideration is filed on the provider portal appeal form. The licensed coordinator remains the filing actor.