Denial Document Analysis

AI parses uploaded denial letters, extracts structured data, and generates appeals automatically.

Denial letter parsed successfully

UHC_Denial_CLM-2026-004756.pdf · Uploaded Feb 22, 2026 · 2 pages · Parsed in 3.2 seconds

Extracted Denial Data

AI-parsed from uploaded denial letter

Claim Information

Claim Number: CLM-2026-004756
Member: George Harris
Member ID: UHC-449827163
Date of Birth: 1958-03-15
Date of Service: 2026-02-05
Provider: Dr. Sarah Chen
Facility: Sunshine Orthopedics & Pain Management

Denial Details

Payer: UnitedHealthcare
Denied Amount: $534
CARC Code: CO-97
CARC Description: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
RARC Code: N519

Code Comparison: Original vs Denied

Side-by-side view of what was submitted and what was denied

Original Encounter Codes

ICD-10-CM Diagnoses

M75.111Incomplete rotator cuff tear, right shoulder

M75.41Impingement syndrome of right shoulder

CPT Procedures Billed

29827Arthroscopic rotator cuff repair — $1850

29826-59Arthroscopic subacromial decompression — $534

Payer Adjudication

Paid

29827Arthroscopic rotator cuff repair — Billed $1850, Allowed $1316

Denied

29826-59Arthroscopic subacromial decompression — Billed $534, Allowed $0

AI-Generated Appeal Letter

References original documentation and CCI guidelines

Dear UnitedHealthcare Medical Review Department,

Re: Appeal of Claim CLM-2026-004756
Member: George Harris (DOB: 03/15/1958, ID: UHC-449827163)
Date of Service: 02/05/2026
Denied Procedure: CPT 29826 — Arthroscopic Subacromial Decompression ($534.00)
Denial Reason: CO-97 (Bundling) / N519 (Invalid Modifier)

I am writing to formally appeal the above denial. The procedures CPT 29827 (arthroscopic rotator cuff repair) and CPT 29826 (subacromial decompression) were performed as separate and distinct surgical procedures during the same operative session.

CLINICAL JUSTIFICATION:

The operative report clearly documents:

1. Rotator Cuff Repair (CPT 29827): Full-thickness supraspinatus tear measuring 2.5 cm was repaired using a double-row suture bridge technique through the posterior and lateral portals. Two medial PEEK anchors (5.5mm) and two lateral knotless anchors were placed.

2. Subacromial Decompression (CPT 29826): A Type II acromion with a prominent anterolateral osteophyte was identified and resected using a motorized burr through a SEPARATE anterolateral portal. This decompression addressed a distinct pathology (impingement syndrome, ICD-10 M75.41) and was not simply part of the exposure for the rotator cuff repair.

Per CCI guidelines and CPT coding principles, modifier 59 (Distinct Procedural Service) is appropriate when:
- The procedures are performed at different anatomic sites or through different surgical approaches
- Each procedure has independent medical necessity
- The operative report documents the distinct nature of each service

All three criteria are met in this case. The original documentation supports separate reporting.

REQUESTED ACTION:
We respectfully request reconsideration and payment of CPT 29826 at the contracted rate of $534.00.

Supporting documentation enclosed:
- Complete operative report (pages 1-3)
- Pre-operative MRI report showing both rotator cuff tear and Type II acromion
- Annotated surgical photographs

Sincerely,
Dr. Sarah Chen, MD, FAAOS
Sunshine Orthopedics & Pain Management
NPI: 1234567890

Auto-generated by Denial Management AgentReady to download as .txt or .html

Self-Learning: Prevention Rule Created

This denial pattern (CO-97 bundling for 29826+29827 with modifier 59 on UHC plans) has been added to your payer intelligence rules. Future encounters with this code combination will be automatically flagged before submission with a documentation checklist requiring: (1) separate portal documentation, (2) distinct pathology for each procedure, and (3) independent medical necessity statement.