Patrick Ashworth

CLM-2024-8680, Medicare, Spinal Fusion L5-S1 (22612)

In appealWith the payer Denied claims

Billed

$44,500

denied Mar 1

Denial risk

58%

winnable with the right notes

Appeal window

lapsed

closes Jun 29

Appeals

none filed yet

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Mar 1
Denied by Medicare
Medical Necessity (50)
Mar 1
Heron scored it: 58% denial risk
3 factors found, appeal path chosen
Mar 1

The denial

Medical Necessity, code 50

Patient: Patrick Ashworth, born 1957-01-12
Payer: Medicare
Procedure: Spinal Fusion L5-S1 (22612)
Diagnosis: M51.16
Denied on: Mar 1, 2026
Assigned to: Heron

Heron says

Medicare LCD criteria require documented failure of 6+ months conservative treatment. Include physical therapy records, pain management notes, and diagnostic imaging. Medicare Redetermination is the first level of appeal, submit within 120 days.

No appeal yet

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Draft it View the claim form

Open Intelligence, pick this claim, and I write the letter from the denial, the payer's rules and the clinical guideline. You sign it here.

What I sent

Clinical notes
Operative report

Everything I know about Patrick

across every queue

Everything for this patient

Open exposure

$44,500

Recovered

1 denied claim0 prior auths0 underpayments0 backlog claims

CLM-2024-8680viewing

22612 · Medical Necessity

$44,500

In appeal

Mar 1