Keiko Mori

CLM-2026-9162, Medicaid, Chemotherapy Infusion, 1st Hour (96413)

In appealWith the payer Denied claims

Billed

$13,547

denied Aug 4

Denial risk

76%

a hard one, worth it

Appeal window

64d

closes Nov 2

Appeals

none filed yet

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Aug 4
Denied by Medicaid
Medical Necessity (50)
Aug 4
Heron scored it: 76% denial risk
3 factors found, appeal path chosen
Aug 4

The denial

Medical Necessity, code 50

Patient: Keiko Mori, born 1972-11-26
Payer: Medicaid
Procedure: Chemotherapy Infusion, 1st Hour (96413)
Diagnosis: C50.911
Denied on: Aug 4, 2026
Assigned to: Heron

Heron says

High recovery risk (76), prioritize this claim in the appeal queue. Medicaid denies 44% of 96413 claims without documented conservative treatment. Clinical notes supporting medical necessity were not attached to the original submission.

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

Clinical notes
Operative report

Everything I know about Keiko

across every queue

Everything for this patient

Open exposure

$88,594

Recovered

3 denied claims3 prior auths2 underpayments5 backlog claims

AUTH-4052

96413 · Chemotherapy Infusion, 1st Hour

96413 · 3d outstanding

96413 · Chemotherapy Infusion, 1st Hour

96417 · Chemotherapy, Additional Sequential

96413 · Medical Necessity

93306 · 29d outstanding

96413 · underpaid 25.6%

96417 · 63d outstanding

96413 · Medical Necessity

96413 · 93d outstanding

96417 · Medical Necessity

71046 · 143d outstanding

72110 · underpaid 29.1%

$368 short

Written off

Nov 28