Appeal — TEST-CLAIM-00096

Date: [Letter Preparation Date]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial — External Claim ID: TEST-CLAIM-00096
Internal Claim ID: 66bfee14-a429-4e29-8b92-c112c2ff8f97
Date of Service: February 10, 2026
Denial Date: February 26, 2026
Denial Code: CO-18 (Exact Duplicate Claim/Service)
Denied Amount: $1,102.97
Appeal Deadline: June 26, 2026

Dear Synthetic Cigna Appeals Department,

This letter constitutes a formal first-level appeal on behalf of [Facility Name] regarding the denial of claim TEST-CLAIM-00096, adjudicated on February 26, 2026, under denial code CO-18 (Exact Duplicate Claim/Service). We respectfully contest this determination and request that Synthetic Cigna overturn the denial, reprocess the claim, and remit payment of the denied amount of $1,102.97.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic Cigna denied claim TEST-CLAIM-00096 on the basis that it constitutes an exact duplicate of a previously submitted and/or adjudicated claim for the same date of service, patient, and procedures. We submit that this denial is not supported by the facts of record and does not satisfy the threshold requirements of Synthetic Cigna's duplicate claim identification rule.

A CO-18 denial is appropriate only when an identical prior claim has been submitted and paid for the same date of service, the same patient, and the same procedures. As outlined in the applicable payer policy, the payer bears the burden of demonstrating that an identical prior claim was previously adjudicated. For the reasons set forth below, that burden cannot be met in this instance.

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II. CLINICAL AND BILLING DISTINCTIVENESS OF SERVICES RENDERED

The claim at issue reflects three clinically distinct and independently documented services rendered on February 10, 2026:

  • CPT 92346 — Ophthalmic examination and evaluation service
  • CPT 23587 — Shoulder procedure
  • CPT 86271 — Laboratory serology test

These three procedure codes represent services spanning separate clinical disciplines — ophthalmology, orthopedic/surgical, and laboratory — performed for documented diagnoses on a single date of service. The combination of these distinct procedures is highly unlikely to represent an inadvertent exact duplicate submission. Each service is independently documented, clinically necessary, and supported by its own procedure-specific records as enclosed herein.

Furthermore, a true CO-18 duplicate would require that a prior claim for the identical combination of patient, date of service, and all three procedure codes was previously submitted and paid. The enclosed claim submission records and Explanation of Benefits (EOB) documentation demonstrate that no prior payment has been received for this identical combination of services, directly rebutting the basis for the CO-18 determination.

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III. SUPPORTING DOCUMENTATION

In support of this appeal, the following documents are enclosed for Synthetic Cigna's review:

  1. Itemized Facility Billing Statement — Confirms the date of service (February 10, 2026) and the specific procedure codes billed (CPT 92346, CPT 23587, CPT 86271) along with associated diagnosis codes (I10.05, N39.69).

  2. Operative Report / Procedure Documentation (CPT 23587) — Clinical documentation establishing the medical necessity and independent nature of the shoulder procedure performed on the date of service.

  3. Laboratory Test Report (CPT 86271) — Report confirming the serology test was ordered, performed, and resulted on the date of service, constituting a distinct billable service.

  4. Claim Submission Records — Records identifying the original submission date and claim details for TEST-CLAIM-00096, demonstrating the timeline of submission and the absence of a prior identical claim.

  5. EOB or Payment Records — Documentation confirming that no prior payment has been issued by Synthetic Cigna for an identical claim encompassing these same procedures for this date of service, refuting the existence of a previously adjudicated duplicate.

  6. Patient Medical Record Documentation — Records linking all three procedures to the date of service and supporting the clinical necessity of each distinct service.

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IV. POLICY ANALYSIS

Under Synthetic Cigna's duplicate claim identification rule, a CO-18 denial requires affirmative evidence of a prior identical claim submission that was previously adjudicated for the same patient, date of service, and procedure codes. The enclosed documentation establishes that:

  • No prior payment record exists for the identical combination of CPT 92346, CPT 23587, and CPT 86271 for the February 10, 2026 date of service;
  • The procedures billed are clinically distinct services that are independently documented and individually medically necessary; and
  • The claim as submitted represents either the sole submission or a legitimate corrected/adjusted claim submission — neither of which qualifies as an exact duplicate under the applicable standard.

Absent evidence of a prior identical adjudicated claim, the CO-18 denial lacks the factual predicate required by Synthetic Cigna's own policy and should be overturned.

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V. REQUESTED REMEDY

[Facility Name] respectfully requests that Synthetic Cigna:

  1. Overturn the CO-18 denial issued on February 26, 2026, for claim TEST-CLAIM-00096;
  2. Reprocess the claim in full in accordance with the applicable plan benefits and contracted rates; and
  3. Remit payment of the denied amount of $1,102.97 to [Facility Name].

Should Synthetic Cigna require additional documentation or clarification to complete its review, please contact [Facility Appeals Contact Name and Information] at your earliest convenience. We request written notification of the appeal determination within the timeframe required by applicable state and federal regulations and the terms of the participating provider agreement.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Date]

Enclosures:
  - Itemized Facility Billing Statement
  - Operative Report / Procedure Documentation (CPT 23587)
  - Laboratory Test Report (CPT 86271)
  - Claim Submission Records
  - EOB or Payment Records
  - Patient Medical Record Documentation