Appeal — TEST-CLAIM-00044

Date: [Insert Date of Letter]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]
[City, State, ZIP]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00044
Internal Claim ID: 47835da7-c9c7-448e-b618-78c6cc31ca48
Payer: Synthetic Cigna
Date of Service: January 20, 2026
Denial Date: February 23, 2026
Denial Code: CO-55
Procedure Codes: CPT 82102, CPT 14809
Diagnosis Codes: E11.40, K21.41
Denied Amount: $634.30
Appeal Deadline: June 23, 2026

Dear Synthetic Cigna Appeals and Grievances Department,

This letter constitutes a formal, first-level appeal on behalf of our facility regarding the denial of Claim Number TEST-CLAIM-00044 for services rendered on January 20, 2026. Synthetic Cigna denied a portion of this claim in the amount of $634.30 under denial code CO-55, asserting that CPT 82102 and CPT 14809 are experimental or investigational in nature. We respectfully but firmly contest this determination and request that the claim be reprocessed and payment issued in full for the denied amount.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic Cigna applied the CO-55 experimental/investigational exclusion to CPT 82102 and CPT 14809, procedures performed in the context of documented diagnoses of Type 2 diabetes with hypoglycemia (E11.40) and gastroesophageal reflux disease with bleeding (K21.41). It is our position that this classification is factually and clinically unsupported. Both procedure codes reflect well-established, routinely performed clinical services that are recognized as standard of care for the documented conditions. The payer's determination appears to misclassify these procedures and does not align with the prevailing body of clinical evidence, peer-reviewed literature, or accepted medical practice.

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II. CLINICAL AND EVIDENTIARY SUPPORT

In support of this appeal, the following documentation is enclosed:

1. Letter of Medical Necessity — The enclosed letter of medical necessity from the treating physician attests that CPT 82102 and CPT 14809 were clinically indicated, medically necessary, and appropriate for the documented diagnoses. The physician's attestation directly addresses the standard-of-care status of these procedures for the patient's specific clinical conditions.

2. Peer-Reviewed Clinical Guidelines and Literature — The enclosed peer-reviewed clinical guidelines and published literature demonstrate that CPT 82102 and CPT 14809 are not experimental or investigational modalities. These documents establish that both procedures are widely recognized and routinely utilized within the clinical community for conditions consistent with E11.40 and K21.41.

3. FDA Approval Documentation — The enclosed FDA approval or status documentation (as applicable) confirms that any applicable devices, reagents, or therapeutic modalities associated with these procedures have received appropriate regulatory clearance or approval, further negating any basis for an experimental/investigational classification.

4. Published Clinical Evidence of Standard-of-Care Status — The enclosed published clinical evidence provides additional demonstration that these procedures are performed routinely in clinical practice and are not investigational in nature.

5. Medical Society Position Statements and Coverage Policies — The enclosed medical society position statements and relevant coverage policies from recognized clinical authorities further support the established, non-experimental status of CPT 82102 and CPT 14809.

6. Documentation of Routine Clinical Adoption — The enclosed documentation illustrates that both procedures are performed regularly across clinical settings and are broadly accepted within the medical community as standard practice for the diagnoses at issue.

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III. POLICY ANALYSIS AND APPLICABLE STANDARD

The payer's experimental/investigational exclusion policy, under which CO-55 was applied, is intended to exclude procedures that lack sufficient clinical evidence of safety and efficacy — i.e., those that remain under investigation and have not achieved acceptance in mainstream clinical practice. CPT 82102 and CPT 14809, as performed in the context of E11.40 and K21.41 on January 20, 2026, do not meet this standard for exclusion. The enclosed body of evidence — including peer-reviewed literature, physician attestation, FDA status documentation, medical society statements, and evidence of routine clinical adoption — collectively and conclusively demonstrates that these procedures are established, non-investigational modalities. Application of the CO-55 denial code to these services therefore constitutes a misapplication of the payer's own experimental/investigational exclusion policy.

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IV. REQUESTED REMEDY

For the foregoing reasons, we respectfully request that Synthetic Cigna:

1. Overturn the CO-55 denial applied to CPT 82102 and CPT 14809 on Claim Number TEST-CLAIM-00044;
2. Reprocess the claim in full in accordance with the applicable plan benefits and contracted rates; and
3. Issue payment of the denied amount of $634.30 upon completion of reprocessing.

We further request written confirmation of receipt of this appeal and a written determination within the timeframe required by applicable plan documents and state and federal regulations.

Should additional clinical documentation, medical records, or further clarification be required to complete review of this appeal, please do not hesitate to contact our facility's billing and appeals department at the information provided below. We remain committed to working cooperatively with Synthetic Cigna to resolve this matter promptly and appropriately.

Thank you for your prompt attention to this appeal.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[City, State, ZIP]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures:
- Letter of medical necessity from treating physician
- Peer-reviewed clinical guidelines and supporting literature
- FDA approval or status documentation
- Published clinical evidence of standard-of-care status
- Medical society position statements and coverage policies
- Documentation of routine clinical adoption