Appeal — TEST-CLAIM-00092

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re:    Formal Appeal of Medical Necessity Denial
       Claim Number:       TEST-CLAIM-00092
       Internal Claim ID:  f1ff6815-3363-4838-9375-cc8283fe1163
       Service Date:       November 28, 2025
       Denial Date:        January 23, 2026
       Procedures:         CPT 28191, CPT 71487
       Diagnoses:          F32.00, E11.02
       Denied Amount:      $2,515.30
       Appeal Deadline:    July 22, 2026

Dear Synthetic Aetna Appeals and Grievances Department,

On behalf of the undersigned facility, we are submitting this formal first-level appeal contesting the denial issued on January 23, 2026, for services rendered on November 28, 2025, under Claim Number TEST-CLAIM-00092. The claim was denied under adjustment reason code CO-50, asserting that the billed services — CPT 28191 (foot/ankle procedure) and CPT 71487 (chest imaging) — were not deemed medically necessary by the payer. For the reasons set forth below, and as substantiated by the enclosed supporting documentation, we respectfully request that Synthetic Aetna overturn this denial, reprocess the claim, and remit payment for the full denied amount of $2,515.30.

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I. BACKGROUND AND BASIS FOR DENIAL

Synthetic Aetna issued a CO-50 medical necessity denial for CPT codes 28191 and 71487 performed on November 28, 2025. The patient carried active diagnoses of Major Depressive Disorder, single episode, severe (ICD-10: F32.00) and Type 2 Diabetes Mellitus with diabetic neuropathy (ICD-10: E11.02) at the time of service. The denial was issued without any accompanying clinical rationale specifying which criteria the services failed to meet, nor was the specific clinical guideline or coverage policy standard used to render the adverse determination communicated to the facility at the time of denial.

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II. ARGUMENT FOR OVERTURN

A. The Procedures Were Reasonable and Necessary for the Documented Diagnoses

CPT 28191 represents a foot and/or ankle procedure directly relevant to the patient's documented diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy (E11.02). Diabetic peripheral neuropathy is a well-established and serious complication of Type 2 Diabetes that frequently necessitates targeted procedural intervention to prevent disease progression, reduce risk of infection, and preserve limb function and patient ambulation. The medical necessity of foot and ankle procedures in the context of diabetic neuropathy is widely supported by accepted clinical guidelines, including those published by the American Diabetes Association and other nationally recognized medical authorities. The enclosed operative report and procedural notes for CPT 28191 confirm that the procedure was performed in direct response to the patient's neuropathic condition.

CPT 71487 represents chest imaging performed in the clinical context of the patient's comorbid conditions. Chest imaging in the setting of complex, multi-diagnosis presentations — including those involving metabolic conditions such as Type 2 Diabetes and the systemic effects associated with Major Depressive Disorder — can be a clinically indicated, reasonable, and necessary diagnostic measure. The enclosed procedural notes, imaging reports, and medical history substantiate the clinical rationale for this service.

B. The Treating Physician Has Documented Medical Necessity

The enclosed letter of medical necessity, authored by the treating physician, expressly documents the clinical justification for both CPT 28191 and CPT 71487 as it relates to the patient's diagnoses of F32.00 and E11.02. The treating physician's determination of medical necessity is a primary and authoritative source of clinical justification and should be afforded substantial weight in this review. The enclosed clinical documentation, patient medical history, and treatment course records further corroborate the physician's assessment that the services rendered on November 28, 2025, were appropriate and necessary given the patient's documented conditions.

C. The Payer Has Not Provided Specific Clinical Criteria Supporting the Denial

Pursuant to applicable claims adjudication standards and the payer's own medical necessity criteria, a CO-50 denial must be grounded in clearly articulated clinical criteria against which the submitted claim was evaluated. No such criteria were communicated to the facility in the denial notice. Accordingly, we respectfully request that Synthetic Aetna disclose the specific clinical criteria, coverage policy, or guideline utilized in rendering the adverse determination for CPT 28191 and CPT 71487 under the above-referenced claim. This disclosure is essential to ensuring a fair and complete appeal process.

D. The Services Meet Accepted Clinical Guidelines

The enclosed peer-reviewed clinical guidelines directly support the medical necessity of both procedures as rendered in the clinical context documented. These guidelines establish that the level and type of care provided on November 28, 2025, align with evidence-based standards for the management of diabetic neuropathy and the associated comorbid conditions present in this case.

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III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

1. Letter of medical necessity from the treating physician
2. Clinical documentation supporting diagnoses F32.00 (Major Depressive Disorder, severe) and E11.02 (Type 2 Diabetes Mellitus with diabetic neuropathy)
3. Operative report and procedural notes for CPT 28191 and CPT 71487
4. Patient medical history and treatment course prior to the service date
5. Peer-reviewed clinical guidelines supporting the medical necessity of the procedures billed
6. Prior conservative treatment records (where applicable)
7. Imaging and diagnostic reports related to the conditions treated

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IV. REQUESTED REMEDY

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

1. Overturn the CO-50 medical necessity denial issued on January 23, 2026, for Claim Number TEST-CLAIM-00092;
2. Reprocess the claim in accordance with the patient's applicable plan benefits; and
3. Remit full payment for the denied amount of $2,515.30.

In the alternative, if this appeal is not resolved in the facility's favor at the first level, we hereby preserve all rights to pursue second-level administrative appeal, external independent review, and any other remedies available under applicable law and the terms of the plan.

We request that a written determination be issued within the timeframe required by applicable state and federal regulations and the plan's appeal procedures. Please direct all correspondence related to this appeal to the contact information listed below.

Thank you for your prompt attention to this matter. We remain available to provide any additional clinical information that may assist in the review of this appeal.

Respectfully submitted,

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

Enclosures: As listed in Section III above