Appeal — TEST-CLAIM-00076

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Cigna

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00076
Service Date: March 7, 2026
Procedure Code: CPT 59834
Diagnosis Code: ICD-10 G43.71
Denied Amount: $557.93
Denial Date: May 1, 2026
Appeal Deadline: August 29, 2026

Dear Appeals and Grievances Department,

On behalf of our facility, we are formally appealing the denial issued by Synthetic Cigna on May 1, 2026, for the above-referenced claim (TEST-CLAIM-00076). The claim was denied under reason code CO-197 (Precertification/authorization/notification absent) for services rendered on March 7, 2026, under procedure code CPT 59834 (vaginal delivery with episiotomy), with a denied amount of $557.93. We respectfully request that Synthetic Cigna overturn this denial and reprocess the claim for payment of the full denied amount.

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GROUNDS FOR APPEAL

It is our position that this denial was issued in error. Prior authorization for the services rendered on March 7, 2026 was obtained prior to the date of service in accordance with Synthetic Cigna's prior authorization requirements. The application of CO-197 to this claim is therefore not supported by the facts of record.

Specifically, we assert the following:

• Prior Authorization Was Obtained: A prior authorization approval was received from Synthetic Cigna before the March 7, 2026 service date. The enclosed prior authorization approval letter from Synthetic Cigna confirms that authorization was granted for the services at issue.

• Timely Submission of Authorization Request: Our facility submitted a prior authorization request to Synthetic Cigna in advance of the service date. The enclosed proof of timely submission — including the fax confirmation and/or electronic submission record — demonstrates that our facility fulfilled its notification obligation in compliance with the payer's prior authorization requirement.

• CO-197 Is Inapplicable Where Authorization Was Secured: Denial code CO-197 denotes the absence of precertification or authorization. Because authorization was affirmatively granted by Synthetic Cigna prior to the date of service, the factual predicate for this denial code is not met. Applying CO-197 under these circumstances is inconsistent with Synthetic Cigna's own prior authorization policy.

• Medical Necessity Is Supported by Clinical Documentation: The enclosed clinical documentation confirms that CPT 59834 was medically necessary and appropriately documented in connection with the patient's care on March 7, 2026.

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SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

1. Prior authorization request submitted to Synthetic Cigna prior to the March 7, 2026 service date
2. Prior authorization approval letter from Synthetic Cigna
3. Proof of timely submission (fax confirmation and/or electronic submission record)
4. Clinical documentation supporting medical necessity for CPT 59834
5. Correspondence logs reflecting authorization requests and payer responses

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REQUESTED REMEDY

We respectfully request that Synthetic Cigna:

1. Overturn the May 1, 2026 denial of claim TEST-CLAIM-00076;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $557.93 in accordance with the applicable plan benefits and contracted rates.

We believe the enclosed documentation clearly establishes that prior authorization was obtained and communicated to Synthetic Cigna in advance of the March 7, 2026 service date, and that the CO-197 denial is not warranted. We respectfully urge a prompt and thorough review of this appeal.

Should your office require any additional information or documentation to complete its review, please do not hesitate to contact our facility's billing and appeals department.

Thank you for your time and attention to this matter.

Respectfully submitted,

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