DATE OF SVC.	TOT CHG		CPT CODE		DESCRIPTION		PPO DISC.			NON COV		ALLOW		PLN PD		PT. RESP.	ORIGINALReason 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