0F 

DEPARTMENT OF LABOR ANLJ 
PC BOX 44291, OLYMPIA, WASHINGTON 98504-4291

June 4, 2019

 

WW CLAIM --
INJURY DATE 
EAST OLYMPIA WA 9854043853 DATE OF BIRTH
CLAIMANT PETERSON
WARREN 

 

Dear Provider:

Thank you for seeking authorization under NuLifiCaLiun 2501745639 to
treat Warren John Peterson under Labor and Industries workers'
compensation coverage

unfortunately, I must deny your reques- After reviewing .h the
claim file and the recommendations of our utilization review
specialists, I have found the requested treatment below is needed for
a medical condition :hat 15 not accepted under the worker's claim.

 





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DENIED 9922: 99223 INITIAL EOSPITAL CARE

If you wish reconsideration of this decision, please send your
request in writing and provide substantiating clinical evidence to
support your position. send If. to me at:

Department of Labor and Industries
PO BOX 44291
Olympia, WA 99504--4291

If we do not receive a request for reconsideration from you within
sixty (60) days of receipt of this letter, this decision becomes
final.

Please feel free to call if you have any questions.

Sincerely,

Sarah Klovas

Claims Manager, Unit 3
PHONE: (360) 90276372
FAX: (350) 902-4567

ORIG: ADMIT PHYS JOFFE AARON DO
CC: WORKER WARREN PETERSON
EMPLOYER THURSTON COUNTY FIRE DIST 6
PROVIDER - JOFFE AARON DO

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