Heron

Zane Whitaker

CLM-2024-8847, Aetna, Total Knee Replacement (27447)

In appealWith the payer Denied claims
Billed
$24,500
denied Apr 28
Denial risk
72%
winnable with the right notes
Appeal window
lapsed
closes May 28
Appeals
1
submitted

What I did

and what comes next
  1. Claim reached Heron
    Posted from the 835 remittance
    Apr 28
  2. Denied by Aetna
    Medical Necessity (50)
    Apr 28
  3. Heron scored it: 72% denial risk
    3 factors found, appeal path chosen
    Apr 28
  4. Heron
    Appeal filed
    Tracking APP-2024-1122
    Apr 30
  5. Waiting on Aetna
    Heron follows up every 14 days until they answer
    soon

The denial

Medical Necessity, code 50

Patient
Zane Whitaker, born 1968-03-14
Payer
Aetna
Procedure
Total Knee Replacement (27447)
Diagnosis
M17.11
Denied on
Apr 28, 2026
Assigned to
Heron
Heron says
Aetna denies 61% of 27447 claims without prior authorization documentation on file. Missing conservative treatment history in 78% of similar rejections at this facility. Recommend attaching clinical notes and imaging before appeal submission.

The appeal

Filed Apr 30, submitted

Draft itView the claim form

Filed under tracking APP-2024-1122. I follow up with Aetna every 14 days until they answer, and the letter will sit here once it is on file.

What I sent

  • Clinical notesApr 30
  • Operative reportApr 30

Everything I know about Zane

across every queue
Everything for this patient
Open exposure
$24,500
Recovered
$0
1 denied claim0 prior auths0 underpayments0 backlog claims
CLM-2024-8847viewing
27447 ยท Medical Necessity
$24,500
In appeal
Apr 28