Esme Thornton

CLM-2024-8776, Aetna, Knee Arthroscopy (29881)

In appealWith the payer Denied claims

Billed

$12,400

denied Apr 3

Denial risk

67%

winnable with the right notes

Appeal window

lapsed

closes May 3

Appeals

submitted

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Apr 3
Denied by Aetna
Medical Necessity (50)
Apr 3
Heron scored it: 67% denial risk
3 factors found, appeal path chosen
Apr 3
Appeal filed
Tracking APP-2024-1098
Apr 8
Waiting on Aetna
Heron follows up every 14 days until they answer
soon

The denial

Medical Necessity, code 50

Patient: Esme Thornton, born 1988-09-05
Payer: Aetna
Procedure: Knee Arthroscopy (29881)
Diagnosis: M23.61
Denied on: Apr 3, 2026
Assigned to: Heron

Heron says

Aetna requires documented failure of conservative treatment for arthroscopic procedures. 67% of similar denials overturned with physical therapy records and MRI confirmation. Attach 6-month physical therapy summary and recent imaging studies.

The appeal

Filed Apr 8, submitted

Draft it View the claim form

Filed under tracking APP-2024-1098. 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 8
Operative reportApr 8

Everything I know about Esme

across every queue

Everything for this patient

Open exposure

$12,400

Recovered

1 denied claim1 prior auth0 underpayments0 backlog claims

AUTH-3258

70553 · Brain MRI with Contrast

29881 · Medical Necessity

$12,400

In appeal

Apr 3