Appeal — TEST-CLAIM-00001

Date: [Date of Submission]

Synthetic Aetna
Appeals and Grievance Department
[Payer Address]

Re:    Formal Appeal of Claim Denial
       Claim Number:       TEST-CLAIM-00001
       Payer:              Synthetic Aetna
       Service Date:       October 29, 2025
       Denial Date:        December 24, 2025
       Procedure Code:     CPT 80678
       Diagnosis Code:     F32.73
       Denied Amount:      $959.93
       Appeal Deadline:    June 22, 2026

Dear Synthetic Aetna Appeals Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the denial of Claim TEST-CLAIM-00001, issued on December 24, 2025. The claim was denied under reason code CO-197 (Precertification/Authorization/Notification Absent) for services rendered on October 29, 2025, specifically CPT code 80678 (Hemoglobin, Glycated [HbA1c]) submitted in conjunction with diagnosis code F32.73 (Major Depressive Disorder, Recurrent Episode, in Remission). The denied amount at issue is $959.93.

We respectfully contest this denial and request that Synthetic Aetna reprocess and pay the denied amount in full. Our grounds for appeal are as follows:


GROUNDS FOR APPEAL

1. Prior Authorization Was Obtained Prior to the Date of Service

Contrary to the basis cited in the CO-197 denial, prior authorization for the services rendered on October 29, 2025, was in fact obtained in advance of the service date. Enclosed with this appeal are the prior authorization approval letter issued by Synthetic Aetna and precertification request documentation bearing approval confirmation, both of which predate the October 29, 2025 service date. These documents demonstrate that our facility fulfilled its precertification obligations in accordance with the plan's requirements. The denial under CO-197 therefore reflects an error in Synthetic Aetna's claims processing, as authorization was on record at the time services were rendered.

We respectfully request that Synthetic Aetna reconcile the enclosed authorization approval against its internal authorization records to confirm that a valid, pre-service authorization was issued for this claim.

2. CPT 80678 May Not Be Subject to Precertification Under the Applicable Plan Terms

In the alternative, and without waiving the foregoing, we submit that CPT 80678 — a routine laboratory test measuring glycated hemoglobin (HbA1c) — is not a service that typically requires precertification under standard plan benefit structures. HbA1c testing is a widely recognized, guideline-supported diagnostic tool used in the monitoring and management of metabolic conditions. The application of a precertification requirement to this routine laboratory service, particularly in the clinical context of diagnosis F32.73, warrants careful review of the plan's precertification schedule. If CPT 80678 is not listed as a service requiring prior authorization under the applicable member benefit plan, the CO-197 denial is not a valid basis for non-payment.

3. Medical Necessity Is Supported by Clinical Documentation

The clinical notes enclosed with this appeal document the medical necessity of CPT 80678 in the context of the patient's diagnosis of Major Depressive Disorder, Recurrent Episode, in Remission (F32.73). Certain pharmacological treatments associated with psychiatric conditions carry metabolic side-effect profiles that necessitate HbA1c monitoring as part of comprehensive patient management. The enclosed clinical notes provide the treating clinician's rationale supporting the ordering of this test on the date of service.

4. Timely and Complete Authorization Submission

The enclosed correspondence and payer authorization system acknowledgment further demonstrate that our facility submitted a precertification request in a timely manner consistent with Synthetic Aetna's plan requirements. Any failure to locate the authorization in the payer's system at the time of claims adjudication constitutes an administrative processing error rather than a failure on the part of our facility to comply with precertification obligations.


SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

  •  Prior authorization approval letter from Synthetic Aetna predating the October 29, 2025 service date
  •  Precertification request documentation with approval confirmation
  •  Correspondence demonstrating timely submission of the authorization request
  •  Payer authorization system records or acknowledgment
  •  Clinical notes supporting medical necessity for CPT 80678 in the context of diagnosis F32.73


REQUESTED REMEDY

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

  1.  Overturn the CO-197 denial issued on December 24, 2025, for Claim TEST-CLAIM-00001;
  2.  Reprocess the claim for CPT 80678, service date October 29, 2025, in accordance with the member's applicable plan benefits; and
  3.  Issue payment of the denied amount of $959.93 to our facility.

Should additional information be required to complete the review of this appeal, please contact our Billing and Appeals Department at [Facility Contact Information]. We request written confirmation of receipt of this appeal and a written determination within the timeframe required under applicable state and federal regulations.

Thank you for your prompt and thorough attention to this matter.

Respectfully submitted,

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