SYNTHETIC HOSPITAL CLINICAL SOURCE. NOT A REAL PATIENT RECORD.
Document: CLN-000076
Claim number: MER-000076
Specialty: Oncology
Author: Rao, Maya MD
Recorded: 2024-10-14

SYNTHETIC CLINICAL SOURCE. NOT A REAL PATIENT RECORD. Claim MER-000076, patient token SYN-PT-29LJT9E8W, service date 2024-10-13. Therapy administration record for Injection, bevacizumab, 10 mg (J9035). Documented dose 46 billing units. Indication Z51.11. Start and stop times are recorded on the administration flowsheet. Ordering physician Rao, Maya MD. Prior therapy history is referenced in the oncology treatment summary. This record is fictional source material for document to claim linkage. It is not a coverage determination and asserts no payment entitlement.

REVIEW REQUIREMENTS
A linked document is not a verified clinical criterion. A qualified reviewer must confirm that
this record satisfies the payer requirement in force on the service date before any appeal.
