Priya Raman

CLM-2026-9136, Medicare, Chemotherapy Infusion, Addl Hour (96415)

In appealWith the payer Denied claims

Billed

$2,203

denied Feb 24

Denial risk

87%

a hard one, worth it

Appeal window

lapsed

closes May 25

Appeals

none filed yet

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Feb 24
Denied by Medicare
Pre-Auth Missing (197)
Feb 24
Heron scored it: 87% denial risk
3 factors found, appeal path chosen
Feb 24

The denial

Pre-Auth Missing, code 197

Patient: Priya Raman, born 1955-06-04
Payer: Medicare
Procedure: Chemotherapy Infusion, Addl Hour (96415)
Diagnosis: C34.90
Denied on: Feb 24, 2026
Assigned to: Heron

Heron says

High recovery risk (87), prioritize this claim in the appeal queue. Prior authorization was not on file at time of service, Medicare auto-denies 96415 without it. 6 similar denials at this facility in the last 90 days for the same reason.

No appeal yet

I can draft one from this claim's history

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

Referral on file

Everything I know about Priya

across every queue

Everything for this patient

Open exposure

$30,147

Recovered

$2,537

7 denied claims2 prior auths1 underpayment4 backlog claims

AUTH-4024

96417 · Chemotherapy, Additional Sequential

96417 · Chemotherapy, Additional Sequential

97530 · 6d outstanding

96417 · Missing Information

97110 · 8d outstanding

96417 · Bundling/Coding Error

93000 · underpaid 13.9%

96417 · Pre-Auth Missing

97530 · 123d outstanding

96417 · 158d outstanding

96415 · Pre-Auth Missing

96417 · Timely Filing

96415 · Medical Necessity

97110 · Medical Necessity

$1,262

Recovered

Nov 26