AI Denial Analysis — A-3005 — Karen White
AI ANALYSIS COMPLETEComplexHospitalAI Confidence: 88%
Denial Summary
Payer
Medicare Part A
Claim #
MC-2025-INP-440281
Patient
Karen White
DOS
01/10–01/13/2025
CPT/DRG
DRG 683
ICD-10
N17.9
Billed Amount
$4,200
Denial Reason
Medical NecessityCARC / RARC
CO-50 / N386
Reason Text
"Inpatient admission not medically necessary. Could have been managed in observation."
Appeal To
Kepro, 5201 W Kennedy Blvd, Tampa FL
Fax: (855) 555-0188
Deadline
Apr 10, 2025
AI Recommendation
Strong case. Creatinine 4.8 (baseline 1.2), potassium 5.9, oliguria, confusion. Meets KDIGO Stage 3 AKI. Focus on severity of illness and intensity of services exceeding observation.
Confidence 88% — Senior review required
AI-Generated Checklist
0/9 itemsMember Benefits (from EOB)
Medicare Part AActive
Coverage
Verified
Benefits confirm coverage. Denial is clinical, not coverage.
Documents Uploaded
denial_letter_karen-white.pdf
eob_karen-white.pdf
clinical_notes_karen-white.pdf
Complexity Flags
Hospital case
AI confidence <98%
Senior review required
Payer call recommended
⚠️ This case requires senior review before proceeding.