Appeal — TEST-CLAIM-00015

Date: [Date of Submission]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00015
Service Date: November 3, 2025
Denial Date: January 30, 2026
Denied Amount: $2,962.41
Appeal Deadline: May 30, 2026

To Whom It May Concern:

On behalf of our facility, we are submitting this formal appeal contesting Synthetic Cigna's denial of Claim TEST-CLAIM-00015, issued on January 30, 2026. The claim was denied under denial code CO-4, asserting that the procedure code is inconsistent with the modifier used. We respectfully disagree with this determination and request that Synthetic Cigna overturn the denial, reprocess the claim, and issue payment of the denied amount of $2,962.41.

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I. BACKGROUND AND BASIS FOR DENIAL

The claim at issue covers services rendered on November 3, 2025, for which our facility billed CPT code 55309 (transurethral resection of prostate) and CPT code 51114 (suprapubic catheterization), with applicable diagnoses including ICD-10 codes F32.65 and E11.49. The total billed amount was $7,881.22, of which $2,962.41 was denied. Synthetic Cigna issued the denial under CO-4, contending that the modifier appended to the relevant procedure code is inconsistent with the code as billed.

Our facility asserts that this denial is not supported by the clinical record, the operative documentation, or current CPT coding guidelines, and that the modifier-code pairing as submitted is valid and appropriate.

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II. GROUNDS FOR APPEAL

A. The Modifier-Code Pairing Is Consistent with CPT Guidelines

The CO-4 denial presupposes an incompatibility between the billed procedure code and the modifier used; however, this characterization is incorrect. The enclosed CPT coding reference and guidance document affirmatively demonstrates that the modifier applied is recognized as appropriate in conjunction with the procedure code(s) billed, in accordance with established CPT editorial guidelines. The denial appears to reflect a mechanical or automated editing determination that is rebutted by authoritative coding guidance.

B. The Operative Report Confirms Both Procedures Were Distinctly Performed

The enclosed operative report provides a detailed, contemporaneous account of the procedures performed on November 3, 2025. This documentation confirms that CPT 55309 and CPT 51114 were each separately and distinctly performed, providing the clinical basis for the modifier selection. The modifier was applied in accordance with CPT instructions to accurately reflect the nature and circumstances of the services rendered, not as an erroneous or arbitrary addition.

C. The Itemized Claim and Modifier Justification Directly Rebut the Denial

The enclosed detailed itemized claim form includes an explicit modifier justification explaining the rationale for the modifier as applied to the billed code(s). This documentation was prepared consistent with Synthetic Cigna's procedure code and modifier compatibility requirements and demonstrates that the coding team applied the modifier intentionally and correctly. The payer's CO-4 denial does not address or acknowledge this justification.

D. Clinical Documentation Supports the Medical Necessity of Each Procedure

The enclosed clinical documentation supporting medical necessity establishes that both procedures billed were medically necessary and clinically appropriate for this patient encounter given the documented diagnoses. This further supports the legitimacy of the coding as submitted, including the modifier usage, as the modifier reflects the actual clinical circumstances of care.

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III. POLICY BASIS

Synthetic Cigna's own policy requires that denials under the procedure code and modifier compatibility requirement be based on a substantive determination that the modifier and code are genuinely incompatible. Where, as here, the operative report, CPT coding guidance, itemized claim with modifier justification, and clinical notes collectively demonstrate that the modifier-code pairing is valid under CPT guidelines, a CO-4 denial cannot be sustained. Upholding this denial in the face of this documentation would be inconsistent with the payer's stated policy basis and with standard industry coding conventions.

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IV. REQUESTED REMEDY

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

1. Overturn the CO-4 denial issued on January 30, 2026, with respect to Claim TEST-CLAIM-00015;
2. Reprocess the claim in full, applying the modifier and procedure codes as originally submitted; and
3. Issue payment of the denied amount of $2,962.41, in addition to any applicable interest accrued pursuant to prompt payment obligations.

Enclosed herewith for your review are the following supporting documents:

- Operative report (November 3, 2025)
- Detailed itemized claim form with modifier justification
- Clinical documentation supporting medical necessity for each procedure
- CPT coding reference or guidance document clarifying proper modifier usage for CPT 55309 and CPT 51114

We are available to provide any additional information or documentation necessary to support the resolution of this appeal. Please direct all correspondence regarding this matter to:

[Provider/Facility Name]
[Contact Name and Title]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Thank you for your prompt attention to this matter. We trust that upon review of the enclosed documentation, Synthetic Cigna will agree that the denial should be overturned and appropriate payment issued.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Facility Name]
[Date]