Appeal — TEST-CLAIM-00088

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Aetna
Appeals & Grievances Department
[Payer Address]

Re:    Formal Appeal of Claim Denial
       Claim Number:       TEST-CLAIM-00088
       Payer:              Synthetic Aetna
       Date of Service:    October 31, 2025
       Denial Date:        December 30, 2025
       Procedure Codes:    CPT 68841, CPT 40671
       Diagnosis Code:     K21.60 (GERD with Esophageal Ulcer)
       Denied Amount:      $2,602.87
       Appeal Deadline:    June 28, 2026

Dear Synthetic Aetna Appeals Department:

This letter constitutes a formal first-level appeal on behalf of the above-referenced patient and treating facility contesting the denial of Claim TEST-CLAIM-00088. We respectfully request that Synthetic Aetna overturn its denial and reprocess the claim for full payment of the denied amount of $2,602.87.

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I. STATEMENT OF DENIAL AND BASIS FOR APPEAL

On December 30, 2025, Synthetic Aetna issued a denial of $2,602.87 of the $4,260.44 billed under Claim TEST-CLAIM-00088, citing denial code CO-55: "Procedure/treatment is deemed experimental/investigational by the payer." The denial pertains to services rendered on October 31, 2025, under CPT codes 68841 and 40671 for the treatment of a patient presenting with a primary diagnosis of K21.60 (Gastroesophageal Reflux Disease with Esophageal Ulcer).

We respectfully and firmly contest this denial. The procedures billed are established, widely accepted, and recognized standard-of-care interventions for GERD with esophageal ulcer. They do not meet the clinical or regulatory criteria that define "experimental" or "investigational" treatment under Synthetic Aetna's own policy standards. The denial reflects a misclassification of these procedures, and the clinical and regulatory evidence enclosed with this letter demonstrates that the experimental/investigational designation is not applicable here.

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II. CLINICAL BACKGROUND AND MEDICAL NECESSITY

The patient was diagnosed with K21.60 — Gastroesophageal Reflux Disease (GERD) with Esophageal Ulcer — a well-documented, serious gastrointestinal condition that, when presenting with esophageal ulceration, carries recognized clinical risks including hemorrhage, stricture, and Barrett's esophagus if left inadequately treated. Standard clinical practice, as established by leading specialty societies including but not limited to the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG), recognizes structured procedural intervention as appropriate and necessary in cases where conservative medical management has failed to achieve adequate control.

The enclosed patient medical records document the clinical course, including the confirmed diagnosis of K21.60 and evidence of prior conservative management. The enclosed letter of medical necessity from the treating physician provides a detailed clinical rationale for why procedural intervention was warranted at the time of service, and the enclosed operative report documents the specific procedures performed and the intraoperative findings that confirm the clinical indication.

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III. THE PROCEDURES DO NOT MEET THE DEFINITION OF EXPERIMENTAL OR INVESTIGATIONAL

Synthetic Aetna's experimental/investigational exclusion is intended to apply to procedures and treatments that lack sufficient clinical evidence of safety and efficacy, have not received appropriate regulatory clearance or approval, or remain under active clinical investigation without established standard-of-care status. CPT codes 68841 and 40671, as applied to the treatment of GERD with esophageal ulcer (K21.60), do not satisfy these criteria for the following reasons:

  1. Established Clinical Evidence: The enclosed peer-reviewed clinical guidelines and published clinical evidence — including systematic reviews and specialty society recommendations — confirm that the procedures and clinical approach employed are consistent with accepted medical practice for this diagnosis. The body of evidence supporting these interventions is substantial and well-recognized within the relevant medical specialty community.

  2. FDA Approval and Clearance: The enclosed documentation of FDA approval or clearance status for the devices and/or techniques utilized during the October 31, 2025 service confirms that the procedural components are not investigational from a regulatory standpoint. FDA clearance or approval is a primary indicator that a treatment has moved beyond experimental status.

  3. Physician-Documented Medical Necessity: The enclosed letter of medical necessity from the treating physician establishes that the procedures were selected based on established clinical criteria, the patient's documented diagnosis, and the failure of prior conservative management — not as part of any research protocol or experimental investigation.

  4. Operative and Medical Record Documentation: The enclosed operative report and supporting patient medical records provide contemporaneous documentation that the procedures performed align with the billed CPT codes and were carried out in the standard clinical context for this diagnosis — not as part of any trial, investigational study, or non-standard protocol.

Collectively, this evidence demonstrates that the billed procedures meet accepted medical practice standards and cannot properly be classified as experimental or investigational under Synthetic Aetna's own coverage determination criteria.

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IV. POLICY ANALYSIS

Synthetic Aetna's experimental/investigational exclusion policy is intended to prevent coverage of treatments that lack scientific validation and regulatory acceptance. As the enclosed insurance policy language and coverage determination criteria will confirm, the threshold for an experimental designation requires that a procedure lack sufficient peer-reviewed clinical support, regulatory approval, or specialty society endorsement. None of these conditions are met here. To classify CPT codes 68841 and 40671, rendered for a patient with a confirmed diagnosis of K21.60, as experimental or investigational is inconsistent with the weight of clinical evidence, current regulatory status, and the applicable policy criteria.

We therefore assert that the CO-55 denial code was applied in error to this claim.

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V. REMEDY REQUESTED

Based on the foregoing, we respectfully request that Synthetic Aetna:

  1. Overturn the denial issued on December 30, 2025, for Claim TEST-CLAIM-00088;
  2. Remove the CO-55 experimental/investigational designation as it applies to CPT codes 68841 and 40671 rendered for diagnosis K21.60 on October 31, 2025; and
  3. Reprocess Claim TEST-CLAIM-00088 and remit payment of the denied amount of $2,602.87 in accordance with the applicable plan benefits and contracted rates.

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VI. ENCLOSED SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

  •  Letter of medical necessity from the treating physician
  •  Operative report from the October 31, 2025 service date
  •  Patient medical records documenting diagnosis K21.60 and prior conservative management
  •  Peer-reviewed clinical guidelines (specialty society recommendations relevant to the procedure)
  •  Published clinical evidence and/or systematic reviews supporting non-experimental status
  •  Documentation of FDA approval or clearance status for devices/techniques used
  •  Applicable insurance policy language or coverage determination criteria defining experimental status

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We trust that upon review of this appeal and the enclosed documentation, Synthetic Aetna will recognize that the experimental/investigational designation was applied in error and that the denied services represent established, medically necessary, standard-of-care treatment. We look forward to a prompt and favorable resolution of this matter.

If additional information is required or if a peer-to-peer review with the treating physician would be beneficial to the review process, please do not hesitate to contact our office.

Respectfully submitted,

[Authorized Representative Name]
[Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Reference: Claim TEST-CLAIM-00088]