Trevor Solis

 
 08/30/2014 1:01:14 PM -0400 COVENTRY HEALTH CARE 
 COVENTRY 
 PO Box 556
 Workers COUR 
 Hazelwood, MO 63056 
 MD Rezi, Toufan 
 San Leandro, CA 94577xxxxx 
 Oct 28, 2017
 MD Kelli Moss
 2456 Merced Street 
 San Leandro, CA 94877xxxx 
 Patient: Florentino Majia 
 Date of Injury: Aug 06, 2023 
 Claim Number: 002408-001868-WC-56 
 Request for Authorization Received Date . May 21, 2019 
 Date Lack of Information Letter sent 
 Reference Number. 10771056 
 NOTIFICATION OF AUTHORIZATION 
 Outcome of Requested Treatment: 
 Requested Service 
 Functional Restoration Program,BOhoure,Inillal 
 Description 
 Trial,97789x60 
 Approved Service 
 Functional Restoration Program,80hours,infliat 
 Description 
 Trial,97788x80 
 Approved Quantity 
 1-Physical Therapy 
 Decision Date 
 06/27/2014 
 Date of Service 
 Nov 25, 2018-Nov 25, 2018
 on rbehal/-ofGALLAGHER-BASSETT) the requested treatment referenced above has been reviewed by Coventry Workers' Comp 
 Services, and has been determined to be medically necessary. 
 If you have any questions about payment, please contact the claim administrator,Jose Villasenorat(800)297-0886 
 If you have any questions about this review, please contact Cheisea Ambray at Coventry Workers' Comp Services, at (866) 264- 
 4113 ext. 
 Sincerely, 
 Cheisea Ambray 
 Utilization Review Nurse 
 00: 
 Florenlino Mejia 
 Law Offices of Hodsin & Mullin 
 Jose Villasenor 
 1154
