730 Cool Springs Boulevard, Suite 800, Franklin, TN 37067

Fax: 888-693-3210
Phone: 888-693-3211
Case Request Results - Your case has been Approved. However there could be pending notifications
Service Order: 148145092 Case Status: Approved
Authorization Number: A70028222 Auth Effective Date: 02/26/2024
Auth End Date: 08/24/2024 Initiated Date: 02/26/2024
Decision Date: 02/26/2024 Decision Type:
Initial

MSK Information
Place Of Service: Outpatient (22) Length Of Stay: 0
Initial Service Request: No

Patient Information
First Name: KERRI Last Name: ABERNATHY
Date of Birth: 04/26/1968 Member ID: 108320327
Address: 501 W GOSS ST, TERRELL, TX, 75160
Insurer: CIGNA HEALTHCARE Program: GWHCIGNA-FI N TX CONNECT HMO

Requested Facility
Name: MESELHY EHAB NPI: 1730573643
Tax ID: Taxonomy Code:
Address: 600 FERRIS AVE, WAXAHACHIE, TX, 751653030
Phone: 2146668079 Fax: 2145949425
Equipment:

Referring Physician
First Name: EHAB Last Name: MESELHY
NPI: 1730573643 Tax ID: *****6629
Address: 600 FERRIS AVE, WAXAHACHIE, TX, 751653030
Phone: 2146668079 Fax: 2145949425
Specialty: PAIN MANAGEMENT

Requested Study
Code Units Description Status Cpt Modifier

27096 1 Injection procedure for sacroiliac joint, Approved LT

arthrography and/or anesthetic/steroid
27096 1 Injection procedure for sacroiliac joint, Approved RT
arthrography and/or anesthetic/steroid

ICD Code Version Description

M46.1 10 Sacroiliitis, not elsewhere classified

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