Appeal — TEST-CLAIM-00083

Date: [Date of Submission]

Via: [Payer-Specified Appeal Submission Method]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00083
Payer: Synthetic Humana
Service Date: March 22, 2026
Denial Date: June 8, 2026
Procedure Code(s): CPT 15130
Diagnosis Code(s): R07.56
Denied Amount: $835.45
Appeal Deadline: August 7, 2026

To Whom It May Concern:

On behalf of [Facility Name] (hereinafter "the Facility"), we respectfully submit this formal appeal contesting the denial of Claim No. TEST-CLAIM-00083, issued by Synthetic Humana on June 8, 2026. The claim pertains to services rendered on March 22, 2026, specifically CPT code 15130 (dermal autograft, trunk), billed at $1,279.04, of which $835.45 was denied.

I. STATEMENT OF DENIAL

The claim was denied under reason code CO-226, indicating that information requested from the billing and/or rendering provider was not provided. It is the Facility's position that this denial should be overturned and the claim reprocessed for payment of the denied amount of $835.45, as complete and responsive documentation is being furnished herewith.

II. BASIS FOR APPEAL

The CO-226 denial code reflects a payer determination that previously requested information was not received — not a finding that the services were medically unnecessary or non-covered under the applicable benefit plan. As such, the denial is administrative in nature and is fully addressable by supplying the documentation that supports both the medical necessity and the billing integrity of the claim.

The Facility possesses the complete documentation package relevant to this claim and is providing it in full with this appeal. Specifically, the Facility asserts the following:

  • The procedure documented under CPT 15130 was performed on March 22, 2026, and is supported by a complete operative report, which is enclosed herewith.

  • The medical necessity of the procedure is substantiated by the clinical records, diagnosis coding under R07.56, and the enclosed physician attestation letter, all of which collectively demonstrate the clinical appropriateness of the service.

  • A detailed itemized billing statement with line-item justification for the denied service is enclosed, clarifying the basis for the amount billed.

  • To the extent any prior written correspondence from Synthetic Humana identified specific documentation items requested, the Facility has endeavored to address each such item in the enclosed documentation package and cover letter.

III. POLICY BASIS

Pursuant to Synthetic Humana's own policy governing CO-226 denials — which are issued when the payer has requested supporting documentation but received no response from the provider — the appropriate remedy upon receipt of the requested information is reprocessing and adjudication of the claim on its merits. Because the Facility now submits the complete operative report, medical records, itemized billing statement, and physician attestation, the stated basis for the denial is fully resolved. Furthermore, this appeal is being submitted prior to the applicable appeal deadline of August 7, 2026, and therefore the Facility's right to a formal appeal review is preserved.

IV. REQUESTED REMEDY

The Facility respectfully requests that Synthetic Humana:

  1. Accept this appeal and the enclosed documentation as satisfying the information requirement underlying the CO-226 denial;
  2. Reprocess Claim No. TEST-CLAIM-00083 in full; and
  3. Issue payment of the denied amount of $835.45 in accordance with the terms of the applicable provider agreement and benefit plan.

V. ENCLOSURES

The following documents are enclosed in support of this appeal:

  1. Itemized operative report for CPT 15130 (service date: March 22, 2026)
  2. Medical records documenting medical necessity for the procedure
  3. Detailed itemized billing statement with line-item justification
  4. Any prior correspondence from Synthetic Humana requesting specific information (if available)
  5. Physician attestation letter addressing the denied service
  6. Clinical documentation supporting diagnosis code R07.56

Should additional information be required to resolve this appeal, please contact the Facility's Patient Financial Services or Denial Management department at [Contact Information]. We request written confirmation of receipt of this appeal and a determination within the timeframe required under applicable state and federal guidelines.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Facility Name]
[Address]
[Phone Number]
[Date]