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Denied claims

Remittance

835 · remit 2026-10-09

Member: Synthetic M-62018, 58 F, Commercial PPO (sample)
Provider: Lakeside Physical Therapy, Physical therapy
Service date: 2026-09-18
Claim no.: 26261-004417

Ln	Code	Billed	Paid	Denial
1	97164-GP PT re-evaluation	$118.00	$96.40	Paid
2	97110-GP ×3 Therapeutic exercise, each 15 min	$141.00	$0.00	CO-50
3	97140-GP Manual therapy, each 15 min	$62.00	$0.00	CO-50

CO-50 Contractual obligation: the provider can't bill the member for this amount. Not covered because the payer did not consider the service medically necessary.

Physical therapy plan of care

poc-1 · 2026-08-04

Patient: Maria Alvarez   DOB: 02/11/1968   MRN: 00731842
Phone: (555) 610-2284

Diagnosis: M54.50 Low back pain.
Functional limitations: Unable to lift more than 10 lb from floor. Sitting tolerance 20 minutes. Oswestry Disability Index 42%.

Goals (8 weeks):
1. Lift 25 lb from floor to waist without increase in pain, to return to warehouse work.
2. Sitting tolerance of 60 minutes.
3. Oswestry Disability Index below 20%.

Plan: Therapeutic exercise and manual therapy, 2 visits per week for 8 weeks (16 visits).
Certified by: J. Brennan, PT, DPT, 08/04/2026.

Progress note, visit 14

note-14 · 2026-09-18

Patient: Maria Alvarez   DOB: 02/11/1968   MRN: 00731842

Visit 14 of 16 in the current plan of care. Re-evaluation performed today.

Objective: Oswestry Disability Index 26% (42% at evaluation). Lifts 20 lb floor to waist with good mechanics and no pain increase. Sitting tolerance 45 minutes.

Assessment: Measurable progress on all three goals. Continued skilled therapeutic exercise is needed to reach the 25 lb lifting goal required for return to warehouse work.

Treatment today: Therapeutic exercise 40 minutes (lifting progression, core stabilization). Manual therapy 10 minutes.

Plan: Continue plan of care, 2 remaining visits.

Replay mode: live calls are off on this deployment.

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