Appeal — TEST-CLAIM-00042

Date: [Letter Date]

To Whom It May Concern,
Appeals and Grievances Department
Synthetic Aetna

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00042
Payer: Synthetic Aetna
Service Date: September 3, 2025
Procedure Code(s): CPT 66626
Diagnosis Code(s): F32.32, M17.11
Denial Date: October 25, 2025
Denied Amount: $1,063.67

Dear Appeals and Grievances Department,

On behalf of our facility, we are submitting this formal written appeal in response to the denial issued on October 25, 2025, for the claim identified above (External Claim ID: TEST-CLAIM-00042). Synthetic Aetna denied a portion of this claim in the amount of $1,063.67 under reason code CO-197, citing the absence of precertification, authorization, or notification for CPT code 66626 (intraocular lens insertion) rendered on September 3, 2025. We respectfully contest this denial and request that Synthetic Aetna overturn its determination and reprocess the claim for full payment of the denied amount.

**Basis for Appeal**

It is our position that prior authorization for the services rendered on September 3, 2025 was, in fact, obtained from Synthetic Aetna in advance of the service date. The CO-197 denial appears to have been issued in error, as the authorization was secured prior to the procedure but was not properly linked to the submitted claim during adjudication. The payer's own records should reflect that this authorization was issued and was active at the time of service.

In support of this appeal, we are enclosing the following documentation:

1. **Prior Authorization Request Letter** — demonstrating that our facility proactively sought authorization from Synthetic Aetna for CPT 66626 prior to the September 3, 2025 service date.

2. **Prior Authorization Approval Document from Payer** — Synthetic Aetna's own approval confirmation, which establishes that the precertification requirement was satisfied before the procedure was performed.

3. **Proof of Timely Submission of Authorization Request** — evidence confirming that the authorization request was submitted to Synthetic Aetna within the required timeframe.

4. **Physician's Letter of Medical Necessity** — clinical justification from the treating physician supporting the medical necessity of CPT 66626 for this patient on the date of service.

Together, these documents demonstrate that the precertification requirement cited in the CO-197 denial code was fully satisfied prior to the September 3, 2025 service date. The denial therefore does not reflect an absence of authorization, but rather an administrative discrepancy in linking the approved authorization to the submitted claim during Synthetic Aetna's adjudication process.

**Policy Analysis**

Synthetic Aetna's prior authorization requirement obligates providers to obtain precertification before rendering covered services such as CPT 66626. Our facility complied with this obligation. Where a payer issues an authorization approval and that approval is not recognized during claims processing, it is appropriate for the payer to reprocess the claim upon presentation of its own approval documentation. We respectfully submit that the enclosed prior authorization approval document from Synthetic Aetna is dispositive evidence that the precertification requirement was met, and that sustaining the CO-197 denial under these circumstances would be inconsistent with the payer's own authorization policies.

**Requested Remedy**

We respectfully request that Synthetic Aetna:

1. Overturn the CO-197 denial issued on October 25, 2025, for External Claim ID TEST-CLAIM-00042;
2. Reprocess the claim for CPT 66626 rendered on September 3, 2025; and
3. Issue payment of the denied amount of $1,063.67 in accordance with the applicable plan benefits and contracted rate.

We believe this appeal presents clear and sufficient grounds for reversal and payment. Should additional information be required to resolve this matter, please do not hesitate to contact our office. We ask that this appeal be reviewed and a written determination be issued within the timeframe required under applicable regulations and plan guidelines.

Thank you for your prompt attention to this matter.

Respectfully submitted,

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

Enclosures:
- Prior Authorization Request Letter
- Prior Authorization Approval Document from Payer
- Proof of Timely Submission of Authorization Request
- Physician's Letter of Medical Necessity