Appeal — TEST-CLAIM-00054

Date: [Date of Submission]

Synthetic BCBS-TX
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00054
Internal Claim ID: 785ec91b-2c23-4c4e-8558-90dd78a4a0e5
Date of Service: February 11, 2026
Denial Date: March 26, 2026
Procedure Code(s): CPT 70981
Diagnosis Code(s): G43.20, E11.56
Denied Amount: $1,316.82
Appeal Deadline: June 24, 2026

Dear Synthetic BCBS-TX Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the denial issued on March 26, 2026, for Claim Number TEST-CLAIM-00054. The claim was denied under reason code CO-55, which classifies the procedure as experimental or investigational. We respectfully and strongly disagree with this determination and request that the claim be overturned and reprocessed for payment of the denied amount of $1,316.82.

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I. BACKGROUND AND BASIS FOR DENIAL

On February 11, 2026, our facility rendered services to the patient identified on the above-referenced claim, including CPT 70981 (MRI of the brain with and without contrast). This procedure was ordered and performed in response to documented clinical indications of migraine with aura (ICD-10: G43.20) and type 2 diabetes mellitus with hypoglycemia (ICD-10: E11.56). The total billed amount for the claim was $2,750.66, of which Synthetic BCBS-TX denied $1,316.82 under denial code CO-55, characterizing CPT 70981 as experimental or investigational.

We submit that this denial is factually and clinically incorrect, and that the applicable experimental/investigational exclusion policy has been misapplied in this instance.

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II. GROUNDS FOR APPEAL

A. CPT 70981 Is an FDA-Cleared, Established Standard-of-Care Procedure

CPT 70981 describes MRI of the brain with and without contrast — a diagnostic imaging modality that has been cleared by the U.S. Food and Drug Administration and is universally recognized throughout the medical community as a standard, non-experimental diagnostic tool. MRI brain imaging is not a novel, emerging, or investigational technology. It is routinely covered by all major commercial payers, Medicare, and Medicaid for a broad range of neurological and metabolic indications. The payer's classification of this procedure as experimental or investigational under CO-55 is inconsistent with the overwhelming clinical, regulatory, and coverage consensus.

Enclosed is FDA approval or clearance documentation (where applicable to CPT 70981), which demonstrates that this imaging modality holds established regulatory standing and cannot appropriately be categorized as experimental.

B. The Procedure Was Medically Necessary for the Documented Diagnoses

The treating physician ordered CPT 70981 based on clinically appropriate indications: migraine with aura (G43.20) and type 2 diabetes with hypoglycemia (E11.56). MRI of the brain with and without contrast is the recognized imaging modality of choice for evaluating patients presenting with migraine with aura, as it enables clinicians to identify underlying structural, vascular, or demyelinating etiologies that may contribute to or mimic aura symptoms. Additionally, hypoglycemic episodes associated with type 2 diabetes can cause neurological sequelae that warrant neuroimaging for appropriate clinical evaluation and management.

The enclosed letter of medical necessity from the treating physician details the specific clinical rationale for ordering this study and confirms that the procedure was integral to the patient's diagnostic workup and treatment planning. The enclosed treatment plan documentation further demonstrates that the imaging was ordered and performed consistent with standard-of-care clinical protocols.

C. Professional Society Guidelines and Peer-Reviewed Literature Support Medical Necessity

Established clinical guidelines from relevant professional societies support the use of brain MRI with and without contrast for the evaluation of migraine with aura and neurological complications associated with diabetes-related metabolic disturbances. The enclosed peer-reviewed published studies and professional society guidelines directly demonstrate that CPT 70981 is a well-accepted, evidence-based intervention for the documented diagnoses — not an experimental one.

These materials collectively establish that the clinical decision to perform this imaging study was grounded in accepted standards of medical practice and supported by a robust body of published literature.

D. Payer's Experimental/Investigational Exclusion Policy Is Inapplicable

Synthetic BCBS-TX's experimental/investigational exclusion policy is intended to apply to procedures, drugs, or technologies that lack sufficient clinical evidence, regulatory approval, or acceptance within the medical community. CPT 70981 meets none of these criteria for exclusion. The enclosed prior authorization records and coverage policies from other major payers further illustrate that this procedure is broadly recognized as a covered, medically necessary service — reinforcing that the CO-55 denial was issued in error.

Application of the experimental/investigational exclusion to a long-standing, FDA-cleared, widely-covered diagnostic imaging procedure represents a misapplication of the policy and results in an unjust denial of a legitimate claim.

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III. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, we have enclosed the following documentation:

1. Letter of medical necessity from the treating physician
2. Peer-reviewed published studies supporting the non-experimental, standard-of-care status of CPT 70981 for the documented diagnoses
3. FDA approval or clearance documentation applicable to CPT 70981
4. Professional society guidelines addressing the use of brain MRI for migraine with aura and diabetes-related neurological evaluation
5. Prior authorization records or coverage policies from other major payers demonstrating routine coverage of CPT 70981
6. Treatment plan documentation reflecting the standard-of-care rationale for the procedure

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

1. Overturn the CO-55 experimental/investigational denial for CPT 70981 rendered on February 11, 2026, under Claim Number TEST-CLAIM-00054;
2. Reprocess the claim in accordance with the patient's applicable benefits; and
3. Issue payment of the denied amount of $1,316.82 to our facility.

We are confident that a thorough review of the enclosed documentation will confirm that CPT 70981 was medically necessary, clinically appropriate, and in no way experimental or investigational. We respectfully urge the review team to give full and fair consideration to this appeal prior to the deadline of June 24, 2026.

Should additional information be required to complete the review of this appeal, please do not hesitate to contact our billing and appeals department at the information below.

Respectfully submitted,

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

Enclosures: As listed in Section III above