Anakin, I would say sometime about a week ago started presenting with like a cough and it was whenever we were on our way to Austin is when I noticed it. It was pretty early in the morning and it kind of just got a little bit harsher over the course of the day and then it just kind of progressed on our way back home the following day. And I took him to the to his vet and the vet listened to him. Everything seemed fine, everything seemed clear. We started him on a cough suppressant. I didn't feel like the cough suppressant was really doing much over the next few days, so I requested that we go back and just see if we could do more for him. We went ahead and we did the the X-ray. His energy levels were a little bit low that day when I brought him in. We found the pneumonia. We've started him on Clavamox.
Next
Claim Overview
Policy Information:
Policy Started On: 2/9/2025
Illness Eligible From: 2/23/2025
Orthopedic Coverage Eligible From: 3/11/2025
Policy Type: Cian, Vet Visit Fee add-on, basic Prev add-on
Claim Information:
Claim Filed On: 3/29/2025
Occurrence Date Per PH: 3/19/2025
Vet Visit Date Per PH: 3/19/2025
Claimed Condition: Coughing
MRR?:
MRR is not completed at this time, BUT we have MR prior to PED/through IWP on file
Pre-Existing Conditions?:
No pre-existing conditions had been identified at the time the claim was filed
Next
Invoice + MR
There were three invoices submitted at once. Find each invoice below (client information intentionally omitted):
Invoice 1
How would you proceed with this claim with the information provided to you? Do we need additional medical records? Why or why not? Do we need an MRR? Why or why not? Think about it before proceeding to the following page!
Invoice 2
Invoice 3
Click on the MR PDF link to open the file if you believe that is beneficial for the Claim Investigation (the "email" is just our email to the clinic).
Next
Claim Investigation Determination
Done thinking? Click on the image below to see how a you should proceed with this claim!
Do we need additional medical records?
Do we need an MRR?
Defend your reasoning!
End
Do we need additonal MR?: No Do we need an MRR: Yes Why?: The MR that's on file shows coughing prior to the PED with the same treatment as the DOL. Remember that we don't want to hold up claims unncessarily so when it's apparent that it's a straightforward denial, we should deny without additional records. If the PH argues that they're unrelated, additional MR can always be collected for review/appeal.
Claim Advo CE - Scenario #5 - Anakin
Lemonade
Created on October 16, 2025
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Transcript
Scenario #5
Anakin
Start
TL;DR + Claim Media
Anakin, I would say sometime about a week ago started presenting with like a cough and it was whenever we were on our way to Austin is when I noticed it. It was pretty early in the morning and it kind of just got a little bit harsher over the course of the day and then it just kind of progressed on our way back home the following day. And I took him to the to his vet and the vet listened to him. Everything seemed fine, everything seemed clear. We started him on a cough suppressant. I didn't feel like the cough suppressant was really doing much over the next few days, so I requested that we go back and just see if we could do more for him. We went ahead and we did the the X-ray. His energy levels were a little bit low that day when I brought him in. We found the pneumonia. We've started him on Clavamox.
Next
Claim Overview
Next
Invoice + MR
There were three invoices submitted at once. Find each invoice below (client information intentionally omitted):
Invoice 1
How would you proceed with this claim with the information provided to you? Do we need additional medical records? Why or why not? Do we need an MRR? Why or why not? Think about it before proceeding to the following page!
Invoice 2
Invoice 3
Click on the MR PDF link to open the file if you believe that is beneficial for the Claim Investigation (the "email" is just our email to the clinic).
Next
Claim Investigation Determination
Done thinking? Click on the image below to see how a you should proceed with this claim!
Do we need additional medical records?
Do we need an MRR?
Defend your reasoning!
End
Do we need additonal MR?: No Do we need an MRR: Yes Why?: The MR that's on file shows coughing prior to the PED with the same treatment as the DOL. Remember that we don't want to hold up claims unncessarily so when it's apparent that it's a straightforward denial, we should deny without additional records. If the PH argues that they're unrelated, additional MR can always be collected for review/appeal.