DALRF16RDTO7 1110/2023 1:13:03 AM PAGE 1/004 Fax Server CONFIDENTIALITY NOTICE: This e-mail transmission, and any documents, files or previous e-mail messages attached to it’may contain confidential or protected health information Pathan to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained i or attached to this transmission iS STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify me by reply e-mail and destroy the original transmission and its attachments without saving them in any mannerDALRFLGRDTO7 1110/2023 1:13:03 AM PAGE 2/004 Fax Server evicore healthcare 400 Buckwalter Place Blvd. BN Ci na Bluffton, SC 29910 ye gna. Date: 6/29/2023 CONFIDENTIAL SHERMAN, TX 75090 Faz: {904) From: eviCore healthcare Phone: 1-866-668-9251 Fax: 1-800-540-2406 CONFIDENTIALITY NOTICE: The attached information to this facsimile transmission is CONFIDENTIAL and is intended only far the use of the recipients) identified above. It may contain confidential and protected health information eubjest to state and federal privacy regulations, including the Health Insurance Portability and Accountability Ace Of 1995 (HIPRA|. If you are not the Intended recipient or a person responsible for Gelivering it to the intended cecipient, you are hereby notified that any disclosure, copying, distribution of use of any of the information contained in oz attached £o this transmission ig STRICTLY PROHIBITED. If you have received this transmission in error, please notify eviCore healthcare immediately by telephone and destroy the transmission and ite attachments without saving them in any manner. Please also notify evicore that all of the Information contained Ln or attached to thie transmlselon hae Been successfully destroyed. ALL Cigna products and services are provided exclusively by ar through such operating Subsidiaries and ot by Cigna Corporation. Such qoerating subsidiaries include Cigna Health and Lite Insursice Company, Connecticut General Life Insurance Company, Evernortn Care colutions, Ine, Evernarth Behavioral Health, Tae., Cigua Health Managenent, Ine. subsidiaries of 190 or services coupany subsidiaries of Cigna Health Comoration and Cigua Dental Health, Inc. Please rater ts your ID card fox the subatdiany that sqauses oy gatdatseass you Gauerse plan. Cayna Health Matagenent Inc., eviCere healthcare MSI, LLC d/b/a evidare hoaltheare and Evernorth Behavioral Heslth, Ine are Licenead of certified utilization review entities. ‘conanDALRFLGRDTO7 1110/2023 1:13:03 AM PAGE 3/004 Fax Server evicore healthcare wie 400 Buckwalter Place Blvd. nee e. Yé Cigna. Date: 6/29/2023 CONFIDENTIAL GARY M HEAD 1800 WELKER DRIVE VAN ALSTYNE, TX 75495 Re: Customer: GARY M HEAD Customer ID #: U39181851 Reference Code: AL95731022 Authorization Effective Date(s}: 6/29/2023 through 12/26/20! Medical Services Setting: Office or Outpatient Facility Dear GARY M HEAD: we want you to know that your health plan requires some care to be reviewed and approved before it is covered. On 06/29/2023, DR. JOHN FLETCHER asked us to review and approve coverage for the following service(s): Procedure | Description aaa35 Fsophagogastroducdenoscopy (EGb), a tiny camera at the end of a flexible tube inserted through the mouth and into th esophagus (a tube that carries food and liquid to the stomach), stomach and small intestine with removal of tissue CIGNA will cover for payment of all applicable CPT service codes performe when prior authorizat. granted for a CPT code within the ZGD- esophagogastroduodenoscopy billing category. No code changes through evicore are required after this case 1s approved, as approval received for one EGD-esophagogastroduadenoscopy procedure cade represents approval for any respective EGD-esophagogastroduadenoscopy codes within the billable code Jist performed on the same date of service. Please contact Cigna at the toll-free number on your ID card for acklitional billing questions related to claims for GI services where an approved authorization is on file. on i Reviewe! eviCore healthcare (eviCore) Cigna partners with evicore, a leading health and wellness company, to manage our Gastroenterology program. eviCore reviews Gastroenterology ALL Clona products and services are provided exclusively by of throagh such operating subsidiaries and not by Cigna Corporation. such qperating subsidiaries include Cigna Health and Lite Tneutance Company, Conuecti cut General Lite Tneurance Company, Everiotth Care Solutions, Tuc., Evernarth Behavioral Health, Inc., Cigna Heslth Management, Inc. subsidiaries of WO or servles company subsidiaries af Cigua fealth Corporation and Cigha Deutal Health, Thee Please refer to your 1D card for the subsidiary that insures or adninisters your benefit plan. Cigna Health Manageuent Inc., aviCore healthcare MSI, LLC d/b/s evidore healtheare and Evernorth Behavioral Health, Ine. are Licenead of certified utilization review entiti ‘coun.DALRF16RDTO7 Tf10/2023 1:13:03 AM PAGE 4/004 Fax Server services to determine if they are medically necessary and covered by your plan. After reviewing your medical information and health plan, we approved this request. evicore has approved the pracedure(s) detailed above. For a full list of codes that can be performed and billed under this authorization, please visit evicore’s website at www.evicore.com/resources/healthplan/cigna. Important reminder: © This letter isn’t a guarantee that your plan will pay for the services. You must be enrolled in the plan and eligible for benefits on the date you receive the service. Please see your plan documents for details about your coverage. You're responsible for your share of any copayments, coinsurance, or other costs. © It does not guarantee that the provider whe requested this service is in-network or will be paid at the in-network rate. This approval also does not guarantee that your plan will cover services from out-of- network providers. Before you receive these services, please call us to confinn whether the requesting provider is in-network. If you have questions, please call Customer Service at the toll-free number on your ID card. An associate is available to help you 24 hours a day, 7 days a week. We look forward to continuing to support you with your health and well- being. Sincerely, evicore healthcare Gastroenterology Utilization Management Programs cet DR, JOHN FLETCHER SHERMAN ENDOSCOPY CENTER, LLC If you have a hearing or speech impairment and use Telecommunications Relay Services (TRS) or 2 Text Telephone (TTY), dial 711 to connect with a TRS operator.