Ingrid Solberg

CLM-2025-9052, Aetna, Chemotherapy Infusion, Addl Hour (96415)

In appealWith the payer Denied claims

Billed

$16,925

denied Dec 19

Denial risk

72%

winnable with the right notes

Appeal window

lapsed

closes Mar 19

Appeals

none filed yet

What I did

and what comes next

Claim reached Heron
Posted from the 835 remittance
Dec 19
Denied by Aetna
Pre-Auth Missing (197)
Dec 19
Heron scored it: 72% denial risk
3 factors found, appeal path chosen
Dec 19

The denial

Pre-Auth Missing, code 197

Patient: Ingrid Solberg, born 2002-03-01
Payer: Aetna
Procedure: Chemotherapy Infusion, Addl Hour (96415)
Diagnosis: C34.90
Denied on: Dec 19, 2026
Assigned to: Heron

Heron says

Prior authorization was not on file at time of service, Aetna auto-denies 96415 without it. 2 similar denials at this facility in the last 90 days for the same reason. Retro-auth may be available within 30 days of service; escalate to the payer's auth desk.