Hiro Sato

CLM-2024-8741, Medicare, Total Knee Replacement (27447)

In appealWith the payer Denied claims

Billed

$26,800

denied Mar 22

Denial risk

45%

good odds

Appeal window

lapsed

closes May 22

Appeals

under review

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Mar 22
Denied by Medicare
Medical Necessity (50)
Mar 22
Heron scored it: 45% denial risk
3 factors found, appeal path chosen
Mar 22
Appeal filed
Tracking APP-2024-1070
Mar 28
Waiting on Medicare
Heron follows up every 14 days until they answer
soon

The denial

Medical Necessity, code 50

Patient: Hiro Sato, born 1955-08-30
Payer: Medicare
Procedure: Total Knee Replacement (27447)
Diagnosis: M17.11
Denied on: Mar 22, 2026
Assigned to: Heron

Heron says

Medicare has specific LCD criteria for total knee replacement, verify all are documented. 45% of Medicare denials for this CPT are overturned with complete documentation. Include BMI, functional assessment, and conservative treatment timeline.

The appeal

Filed Mar 28, under review

Draft it View the claim form

Filed under tracking APP-2024-1070. I follow up with Medicare every 14 days until they answer, and the letter will sit here once it is on file.

What I sent

Clinical notesMar 28
Operative reportMar 28

Everything I know about Hiro

across every queue

Everything for this patient

Open exposure

$26,800

Recovered

1 denied claim1 prior auth0 underpayments0 backlog claims

AUTH-3291

29881 · Knee Arthroscopy

27447 · Medical Necessity

$26,800

In appeal

Mar 22