CLM-2026-006

Denied

Patricia Lee · DOS Dec 1, 2025 · Medicare Part B

Patient Information

PL

Patricia Lee

DOB: Sep 12, 1948 · Female

(555) 678-9012

p.lee@email.com

Naples, FL 34102

Insurance

Medicare Part B

Member ID: 1PL2-AB3-QR45

Group: N/A

Effective: Sep 1, 2013

Primary

Medical Codes

A5500

Diabetic shoe, custom molded

Qty: 1

$620.00

Verified
A5512

Multi-density insert, custom

Qty: 3

$270.00

Verified

Attachments (1)

diabetic_shoe_rx.pdf

0.2 MB·
prior auth
rejected

Activity Timeline

Encounter recorded

Dec 1, 2025 · System

Pre-auth submitted

Dec 2, 2025 · System

Claim submitted

Dec 4, 2025 · System

Claim denied – missing certification

Dec 20, 2025 · Medicare

Claimly Denial Prediction

High risk

Get prior authorization before submitting

These codes may not be covered — confirm with the payer before submitting

Claimly Suggestions

Obtain podiatrist certification before resubmitting

File first-level appeal with supporting documentation

Billing Summary

Procedure Charge$890.00
Insurance Pays$712.00
Patient Responsibility$178.00

Risk Assessment

82
HIGH RISK

Medicare requires additional documentation for diabetic shoe coverage

Missing podiatrist certification form

Predicted Payment$0.00
Expected DateN/A
Confidence Interval$0.00 $569.00

Pre-Authorization

Actions

Agent Reasoning File Appeal