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Name of Patient: Name of URA/Payer: Name of Provider: M2-04-1248-01 Royal Insurance Company of America (ER, Hospital, or Other Facility) Name of Physician: (Treating or Requesting) Karl Swann, MD June 14, 2004 An independent review of the above-referenced case has been completed by a neurosurgeon medical physician. The appropriateness of setting and medical necessity of proposed or rendered services is determined by the application of medical screening criteria published by Texas Medical Fo.

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