EXPLANATION OF BENEFITS (EOB) ============================================================== UnitedHealthcare Insurance Company P.O. Box 740800 Atlanta, GA 30374-0800 Date of Notice: January 15, 2026 Member ID: UHC-9847261035 Group Number: GRP-482910 Claim Number: CLM-2026-0115-48291 ============================================================== PATIENT INFORMATION ------------------- Patient Name: Jane Smith Date of Birth: March 22, 1985 Provider: Dr. Robert Chen, MD - Orthopedic Associates Facility: Memorial Regional Medical Center ============================================================== CLAIM DETAILS ------------------- Date of Service: December 18, 2025 Procedure Code: CPT 27447 - Total Knee Arthroplasty Diagnosis Code: ICD-10 M17.11 - Primary osteoarthritis, right knee Billed Amount: $45,750.00 Allowed Amount: $0.00 Patient Responsibility: $45,750.00 ============================================================== DENIAL INFORMATION ------------------- Denial Code: CO-50 Denial Reason: SERVICES DENIED AS NOT MEDICALLY NECESSARY The requested procedure (Total Knee Arthroplasty, CPT 27447) has been determined to not meet our criteria for medical necessity based on the clinical information provided. Our medical review determined that: - Conservative treatment options have not been sufficiently exhausted - Physical therapy documentation does not demonstrate adequate trial period (minimum 6 months required per UHC Clinical Policy 2024-KR-001) - BMI-related surgical clearance documentation was not included ============================================================== YOUR APPEAL RIGHTS ------------------- You have the right to appeal this decision. Your appeal must be submitted within 180 days of this notice. Appeals may be submitted to: UnitedHealthcare Appeals Department P.O. Box 30432 Salt Lake City, UT 84130-0432 Fax: 1-801-994-1349 Please include: - This EOB or claim reference number - A letter explaining why you disagree with this decision - Any additional clinical documentation supporting medical necessity For questions, call Member Services at 1-800-555-0199 ============================================================== THIS IS NOT A BILL ==============================================================