First Health 10/23/98 and 04/30/99 spreadheets combined, with "outside review" updates.

Table Heading(s)

No Controversy or Appeal

Questioned or Appealed

Resolved, no Disbute

Adverse action or discrepancy

DATE OF SVC.	TOT CHG	CPT CODE	DESCRIPTION	PPO DISC.	NON COV	ALLOW	PLN PD	PT. RESP.	ORIGINAL Reason For Denial	Reviewed Reason For Denial/ Comment
1/24/96	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $8.25
1/24/96	100.00	80019	19 Clinical Chemistry Tests	60.80		39.20	39.20
1/24/96	150.00	80072	Arthritis Panel	81.75		68.25	68.25
1/24/96	100.00	80092	Thyroid Panel With Tsh	24.51		75.49	75.49
1/24/96	75.00	82787	Immunoglobulin Subclasses			75.00	75.00
1/24/96	75.00	82787	Immunoglobulin Subclasses		75.00				Duplicate Charges	Duplicate Charges
1/24/96	75.00	82787	Immunoglobulin Subclasses		75.00				Duplicate Charges	Duplicate Charges
1/24/96	75.00	82787	Immunoglobulin Subclasses		75.00				Duplicate Charges	Duplicate Charges
1/24/96	75.00	83520	Immunoassays, Not Specified	27.82		47.18	47.18
1/24/96	75.00	84165	Protein; Electrophoretic	29.85		45.15	45.15
1/24/96	50.00	84436	Thyroxine; Total	22.00		28.00	28.00
1/24/96	35.00	84479	Thyroid Hormone	11.20		23.80	23.80
1/24/96	100.00	84481	Triiodothyronine T3; Free	30.00		70.00	70.00
1/24/96	25.00	85007	Blood Count; Man. Diff	18.00		7.00	7.00
1/24/96	35.00	85024	Hemogram & Platelet Count	22.40		12.60	12.60
1/24/96	20.00	85048	White Blood Cell	13.00		7.00	7.00
1/24/96	25.00	85651	Sedimentation Rate	15.20		9.80	9.80
1/24/96	100.00	86320	Imminoelectrophoreisis	44.00		56.00	56.00
1/24/96	75.00	86329	Immunodiffusion	22.50		52.50	52.50
1/24/96	75.00	86329	Immunodiffusion		75.00				Duplicate Charges	Duplicate Charges
1/24/96	75.00	86329	Immunodiffusion		75.00				Duplicate Charges	Duplicate Charges
1/24/96	75.00	86378	Migration Inhibitory Factor			75.00	75.00
1/24/96	100.00	86644	Cytomegalovirus		100.00				Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness	Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness
1/24/96	100.00	86645	CYTOMEGALOVIRUS,Igm	51.88		48.12	48.12
1/24/96	50.00	86694	Herpes Simplex Non Specific		50.00				Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness	Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness
1/24/96	25.00	86694	Herpes Simplex Non Specific		25.00				Duplicate Charges	Duplicate Charges
1/24/96	50.00	86695	Herpes Simplex, Type 1	0.93		49.07	49.07
1/24/96	25.00	86695	Herpes Simplex, Type 1		25.00				Duplicate Charges	Duplicate Charges
1/24/96	50.00	86701	Hiv-1			50.00	50.00
1/24/96	50.00	86762	Rubella		50.00				Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness	Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness
1/24/96	25.00	86762	Rubella		25.00				Duplicate Charges	Duplicate Charges
1/24/96	50.00	86777	Toxoplasma		50.00				Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness	Not Med. Nec; Torch Screen Is For Poss Exposure To 4 Diff Organisms, Only 1 Of Which Could Even Remotely Be Considered As The Cause For Patients Illness
1/24/96	25.00	86777	Toxoplasma		25.00				Duplicate Charges	Duplicate Charges
1/24/96	100.00	86787	Treponema Pallidum Varicella	60.37		39.63	39.63
1/24/96	100.00	86787	Treponema Pallidum Varicella		100.00				Duplicate Charges	Duplicate Charges
1/24/96	100.00	86800	Thyroglobulin	59.40		40.60	40.60
1/24/96	125.00	88180	Flow Cytometry			125.00	125.00
1/24/96	125.00	88180	Flow Cytometry		125.00				Duplicate Charges	Duplicate Charges
1/24/96	250.00	99244	Office Cons. New Or Existing	85.68		164.32	164.32
2/9/96	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $8.25
2/9/96	100.00	80019	19 Clinical Chemistry Tests	60.80		39.20	29.20
2/9/96	100.00	80092	Thyroid Panel With Tsh	24.51		75.49	75.49
2/9/96	100.00	82378	Carcinoembryonic Antigen	50.93		49.07	49.07
2/9/96	50.00	84436	Thyroxine; Total	22.00		28.00	28.00
2/9/96	35.00	84479	Thyroid Hormone	11.20		23.80	23.80
2/9/96	100.00	84481	Triiodothyronne T3; Free	30.00		70.00	70.00
2/9/96	35.00	85024	Hemogram & Platelet Count	22.40		12.60	12.60
2/9/96	25.00	85651	Sedimentation Rate	15.20		9.80	9.80
2/9/96	50.00	86060	Antistreptolysin 0; Titer	23.75		26.25	26.25
2/9/96	50.00	86140	C Reactive Protein	35.30		14.70	14.70
2/9/96	55.00	86140	C Reactive Protein		55.00				Duplicate Charges	Duplicate Charges
2/9/96	100.00	86215	Deoxyriboneucleic Acid Antibodies	66.40		33.60	33.60
2/9/96	50.00	86255	Flourescent Antibody Screen	20.04		29.96	29.96
2/9/96	75.00	86255	Flourescent Antibody Screen	45.04		29.96	29.96
2/9/96	75.00	86256	Flourescent Antibody Titer	33.00		42.00	42.00
2/9/96	75.00	86256	Flourescent Antibody Titer		75.00				Duplicate Charges	Duplicate Charges
2/9/96	75.00	86256	Flourescent Antibody Titer		75.00				Duplicate Charges	Duplicate Charges
2/9/96	75.00	86376	Microsomal Antibodies	35.80		39.20	39.20
2/9/96	75.00	86378	Migration Inhibitory Factor			75.00	75.00
2/9/96	225.00	86617	Borrelia Burgdorferi	174.99		50.01	50.01
2/9/96	225.00	86617	Borrelia Burgdorferi		225.00				Duplcate Charges	Duplicate Charges
2/9/96	100.00	86800	Thyroglobulin	59.40		40.60	40.60
2/9/96	150.00	99215	Office Visit	53.08		96.92	96.92
2/9/96 – The 5/30/99 Spreadsheet also shows three line items that were not on the original spreedsheet. These 3 items, totalling $250.00 (submitted) had a plan paid amount of $159.95
3/20/96 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials.
5/31/96 – The 5/30/99 Spreadsheet shows 24 line items that were not on the original spreadsheet. 4 denials for "duplicate charge". No other problems or denials.
6/5/96 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. Denial of "excludes missed appts, phone conversations.
7/11/96 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials
8/12/96 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials
9/16/96 – The 5/30/99 Spreadsheet shows 16 line items that were not on the original spreadsheet. 5 denials for "duplicate charge". No other problems or denials.
10/17/96 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials
11/26/96 – The 5/30/99 Spreadsheet shows 8 line items that were not on the original spreadsheet. No denials
12/2/96 – The 5/30/99 Spreadsheet shows 3 line items that were not on the original spreadsheet. No denials
12/10/96	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $8.25
12/10/96	30.00	85610	Prothrombin Time	4.50		25.50	25.50	4.60
12/13/96	30.00	84999	Unlisted Chemistry Procedure		30.00				No Documentation To Support Charge	No Documentation to support charge
12/13/96	30.00	85610	Prothrombin Time	4.50		25.50	25.50
12/13/96	15.00	99000	Specimen Handling		15.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $15
12/19/96 – The 5/30/99 Spreadsheet shows 3 line items that were not on the original spreadsheet. No denials
1/2/97	20.00	36415	Routine Venipuncture		25.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $6.60
1/2/97	30.00	85610	Prothrombin Time	4.50		25.50	20.40	5.10
1/2/97	35.00	85732	Thromboplastin Time; Subs.	15.40		19.60	15.68	3.92
1/27/97 – The 5/30/99 Spreadsheet shows 7 line items that were not on the original spreadsheet. No denials
2/13/97 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials
2/25/97 – The 5/30/99 Spreadsheet shows 3 line items that were not on the original spreadsheet. No denials
3/12/97 – The 5/30/99 Spreadsheet shows 1 line item that was not on the original spreadsheet. No denials
4/10/97 – The 5/30/99 Spreadsheet shows 7 line items that were not on the original spreadsheet. No denials
5/8/97 – The 5/30/99 Spreadsheet shows 7 line items that were not on the original spreadsheet. No denials
5/22/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $6.60
5/22/97	100.00	80019	19 Clinical Chemistry Tests		100.00				No Medical Necessity-Not Relevant Or Indicated Given Patient's Symptoms At Time Of Visit	Reconsideration following outside review, paid $67.00
5/22/97	35.00	85024	Hemogram & Platelet Count	18.02		16.98	13.58	3.37
5/22/97	30.00	85610	Prothrombin Time	8.00		22.00	17.60	4.40
5/22/97	25.00	85651	Sedimentation Rate		25.00				Test Could Not Indicate Positive Response To Treatment As They Were Unremarkable Before Treatment Was Started	Reconsideration following outside review, paid $17.00
5/22/97	50.00	86140	C Reactive Protein		50.00				Test Could Not Indicate Positive Response To Treatment As They Were Unremarkable Before Treatment Was Started	Reconsideration following outside review, paid $34.00
5/22/97	100.00	99212	Office Visit	52.00		48.00	38.40	9.60
6/9/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $6.60
6/9/97	65.00	80019	19 Clinical Chemistry Tests		65.00				Medical Necessity Not Established	Medical Necessity Not Established
6/9/97	35.00	85024	Hemogram & Platelet Count	18.02		16.98	13.47	3.40
6/9/97	30.00	85610	Prothrombin Time		30.00				Medical Necessity Not Established	Medical Necessity Not Established
6/9/97	400.00	86256	Flourescent Antibody Titer	358.00		42.00	3.60	0.90	$30.00 Overpayment From 81072454040h Recouped	$30.00 Overpayment From 81072454040h Recouped
6/9/97	65.00	99212	Office Visit	12.00		48.00	38.40	9.60
6/13/97 – The 5/30/97 Spreadsheet shows 4 line items, one reconsidered & paid $12.00, one "no documentation to support charge", denied $20.00 – These items did not show on the original, appealed spreadsheet.
6/16/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	NO DENIAL REASON ON 5/30/99 SPREADSHEET BUT SHOWS $6.60 PLAN PAID -- EOB SHOWS $8.25 PAID,
6/16/97	65.00	80019	19 Clinical Chemistry Tests	25.80		39.30	31.36	7.84
6/16/97	35.00	85024	Hemogram & Platelet Count		35.00				Results Not Effective As Antibiotics Were Completed About This Time	Results Not Effective As Antibiotics Were Completed About This Time
6/16/97	30.00	85610	Prothrombin Time	16.78		13.22	10.57	2.65
7/3/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $6.60
7/3/97	65.00	80019	19 Clinical Chemistry Tests	25.80		39.20	31.36	7.84
7/3/97	35.00	85024	Hemogram & Platelet Count	18.02		16.98	13.58	3.40
7/3/97	30.00	85610	Prothrombin Time	16.78		13.22	10.57	2.65
7/3/97	65.00	99213	Office Visit	21.90		43.10	34.48	8.62
7/30/97	65.00	99213	Office Visit		65.00				Documentation States "Unchanged"; No Med Necessity Established	Reconsideration following outside review, paid $24.80
9/17/97	75.00	J0696	Rocephin	37.50		37.50	30.00	7.50
9/17/97	10.00	J3490	Unclassified Drugs		10.00				Global; Should Not Be Separate Charge	Global; Should Not Be Separate Charge
9/17/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Reconsideration following outside review, paid $6.60
9/17/97	65.00	80019	19 Clinical Chemistry Tests	9.75		55.25	44.20	11.05
9/17/97	35.00	85024	Hemogram & Platelet Count	5.25		29.75	23.80	5.95
9/17/97	30.00	85610	Prothrombin Time	8.00		22.00	17.60	4.40
9/17/97	25.00	85651	Sedimentation Rate		25.00				Results Never Abnormal; Could Not Be Used To Document Response To Therapy	Results Never Abnormal; Could Not Be Used To Document Response To Therapy
9/17/97	35.00	86140	C Reactive Protein		35.00				Results Never Abnormal; Could Not Be Used To Document Response To Therapy	Results Never Abnormal; Could Not Be Used To Document Response To Therapy
9/17/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Global; Should Not Be Separate Charge
9/17/97	65.00	99213	Office Visit	17.00		48.00	38.40	9.60
9/24/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Global; Should Not Be Separate Charge
9/24/97	150.00	J3490	Rocephin	112.50		37.50	30.00	7.50
9/24/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Global; Should Not Be Separate Charge
9/24/97	65.00	99211	Office Visit	30.00		35.00	28.00	28.00
9/29/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
9/29/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
9/29/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
9/29/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/2/97	10.00	J3490	Unclassified Drugs		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/2/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Related to ineligible lab charges
10/2/97	65.00	80019	19 Clinical Chemistry Tests		65.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	35.00	85024	Hemogram & Platelet Count		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	30.00	85610	Prothrombin Time		30.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	25.00	85651	Sedimentation Rate		25.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	35.00	86140	C Reactive Protein		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/2/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/2/97	65.00	99213	Office Visit		65.00				Medical Necessity Not Established	Medical Necessity Not Established
10/6/97 – The 5/30/97 Spreadsheet shows 4 line items that did not show on the original, appealed spreadsheet. Of these 4 items, 2 were "Plan Paid" in the amount of $45.50, with 2 denied in the amount of $60.00, denial reason of "Global; should not be separate charge"
10/9/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/9/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/9/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/9/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/14/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/14/97	20.00	36415	Routine Venipuncture		20.00				Global; Should Not Be Separate Charge	Global; Should Not Be Separate Charge
10/14/97	65.00	80019	19 Clinical Chemistry Tests		65.00				Medical Necessity Not Established	Medical Necessity Not Established
10/14/97	125.00	84402	Testosterone; Free	54.23		70.77	56.62	14.15
10/14/97	125.00	84403	Testosterone; Total	80.65		44.35	35.48	8.87
10/14/97	35.00	85024	Hemogram & Platelet Count		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/14/97	30.00	85610	Prothrombin Time	16.78		13.22	10.58	2.64
10/14/97	25.00	85651	Sedimentation Rate		25.00				Medical Necessity Not Established	Medical Necessity Not Established
10/14/97	35.00	86140	C Reactive Protein		35.00				Results Never Abnormal; Could Not Be Used To Document Response To Therapy	Results Never Abnormal; Could Not Be Used To Document Response To Therapy
10/14/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/14/97	50.00	99212	Office Visit	19.00		31.00	24.80	6.20
10/20/97	10.00	J3490	Lidocaine		10.00				Need Clinical Info	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/20/97	75.00	J0696	Rocephin		75.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/20/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/20/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/23/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/23/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/23/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/23/97	50.00	99212	Office Visit		50.00				Medical Necessity Not Established	Medical Necessity Not Established
10/27/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/27/97	37.50	J0696	Rocephin		37.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/27/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/27/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
10/30/97	75.00	J0696	Rocephin		75.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/30/97	50.00	90782	Testerone Cypionate		50.00				No Medical Necessity As Test Results Were Not Abnormal	No Medical Necessity As Test Results Were Not Abnormal
10/30/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
10/30/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
11/3/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/3/97	75.00	J0696	Rocephin		75.00				Medical Necessity Not Established	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/3/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/3/97	50.00	99212	Office Visit		50.00				Medical Necessity Not Established	Medical Necessity Not Established
11/6/97	10.00	J3490	Lidocain		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/6/97	75.00	J0696	Rocephin		75.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/6/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/6/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
11/10/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/10/97	75.00	J0696	Rocephin		75.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/10/97	35.00	88211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
11/10/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/13/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/13/97	75.00	J0696	Rocephin		75.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/13/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/13/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
11/13/97 – The 5/30/97 Spreadsheet shows 2 line items that did not show on the original, appealed spreadsheet. Of these 2 items for a total of $100.00 submitted charges, 1 was denied as "No medical necessity as test results were not abnormal", the second denied as "Related to inelibible injection charge
11/17/97	10.00	J3490	Lidocain		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/17/97	150.00	J3490	Rocephin		150.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/17/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/17/97	35.00	99211	Office Visit	15.63		19.37	15.50	3.87		I’m confused!!! In all previous cases where the Rocephin, Lidocain, and Ther./Diagnostic Injection charges were denied, the Office Visit was also denied. How come they paid for this one. What was in the chart that made it different?
11/22/97	65.00	99213	Office Visit		65.00				Global; Should Not Be Separate Charge	Medical Necessity Not Established
11/24/97	10.00	J3490	Lidocaine	1.50	8.50				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/24/97	150.00	J3490	Rocephin	22.50	127.50				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/24/97	50.00	90782	Ther./Diagnostic Injection	32.84	17.16				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
11/24/97	50.00	99212	Office Visit		50.00				Global; Should Not Be Separate Charge	Medical Necessity Not Established
12/01/97 – The 5/30/97 Spreadsheet shows 4 line items that did not show on the original, appealed spreadsheet. Of these 4 items for a total of $245.00 submitted charges, 3 were "Plan Paid" totalling $124.30, with 1 denied as "Global’ should not be separate charge".
12/4/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/4/97	150.00	J3490	Rocephin		150.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/4/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/4/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
12/8/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/8/97	150.00	J3490	Rocephin		150.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/8/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/8/97	50.00	99212	Office Visit		50.00				Medical Necessity Not Established	Medical Necessity Not Established
12/11/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/11/97	150.00	J3490	Rocephin		150.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/11/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/11/97	35.00	99211	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
12/15/97	10.00	J3490	Lidocaine		10.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/15/97	150.00	J3490	Rocephin		150.00				Intramuscular Injections Not Effective For Eradication Of Lyme Disease *	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/15/97	50.00	90782	Ther./Diagnostic Injection		50.00				Global; Should Not Be Separate Charge	Intramuscular Injections Not Effective For Eradication Of Lyme Disease *
12/15/97	35.00	99212	Office Visit		35.00				Medical Necessity Not Established	Medical Necessity Not Established
12/18/97	150.00	J3490	Unclassified Drugs			150.00	120.00	30.00
12/18/97	10.00	J3490	Unclassified Drugs			10.00	8.00	2.00
12/18/97	20.00	36415	Routine Venipuncture	11.75		8.25	6.60	1.65
12/18/97	65.00	80019	19 Clinical Chemistry Tests	25.80		39.20	31.36	7.84
12/18/97	75.00	84165	Protein; Electrophoretic	38.88		36.12	28.89	7.23
12/18/97	35.00	85024	Hemogram & Platelet Count	18.02		16.98	13.58	3.40
12/18/97	30.00	85610	Prothrombin Time	4.50		25.50	20.40	5.10
12/18/97	30.00	85730	Thromboplastin Time		30.00				Medical Necessity Not Established	Medical Necessity Not Established
12/18/97	100.00	86320	Immunoelectrophoresis	52.45		47.55	38.04	9.51
12/18/97	50.00	90782	Ther./Diagnostic Injection			50.00	40.00	10.00
12/18/97	100.00	99214	Office Visit	37.08		62.92	50.34	12.58
12/22/97 – The 5/30/97 Spreadsheet shows 4 line items that did not show on the original, appealed spreadsheet. All 4 allowed.
1/22/98 – The 5/30/97 Spreadsheet shows 1 line item that did not show on the original, appealed spreadsheet. Allowed.

* Medical literature indictes that it is not possible to deliver an effective treatment dose for eradication of Lyme disease with this antibiotic using the intramuscular route, as 2 mg. daily intravenously are required to accomplish this. Documentation includes "Lyme Borreliosis and Related Disorders," by Kenneth Liegner, MD and Conn's Current Therapies. 04/30/99