Appeal — TEST-CLAIM-00013

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00013
Internal Claim Reference: c47206c8-bf91-4ecd-810f-bf9046b665a9
Service Date: April 20, 2026
Procedure Code(s): CPT 71694
Diagnosis Code(s): ICD-10 J45.58
Denial Date: June 7, 2026
Denied Amount: $290.76
Appeal Deadline: July 7, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of the rendering facility regarding the denial of Claim TEST-CLAIM-00013, issued by Synthetic Medicaid-TX on June 7, 2026. We respectfully request that this denial be overturned and that the claim be reprocessed for payment of the denied amount of $290.76.

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I. BASIS FOR DENIAL

The claim was denied under remark code CO-4, with the stated rationale that the procedure code is inconsistent with the modifier used. Specifically, the payer has determined that the modifier appended to CPT code 71694 (computed tomography of the chest, with or without contrast material), billed for services rendered on April 20, 2026, is incompatible with that procedure code under the payer's procedure code and modifier compatibility requirements.

We respectfully disagree with this determination and submit that the modifier in question was both clinically justified and correctly applied in accordance with current CPT guidelines and the patient's documented clinical presentation.

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II. GROUNDS FOR APPEAL

A. The Modifier Was Clinically Appropriate and Correctly Applied

The patient presented with a primary diagnosis of unspecified asthma with acute exacerbation (ICD-10 J45.58) on the date of service. Given the patient's acute respiratory presentation, a computed tomography study of the chest was medically necessary to evaluate the extent and nature of the pulmonary involvement. The modifier appended to CPT 71694 was applied to accurately reflect the circumstances under which the service was rendered, in conformance with applicable CPT coding guidelines.

The enclosed procedure note from April 20, 2026 documents the clinical scenario in detail and provides the factual basis demonstrating that the modifier was not only appropriate but required to accurately describe the service as performed. The enclosed modifier justification documentation further clarifies the coding rationale and establishes that the modifier's application is consistent with CPT guidelines governing code 71694.

B. The Denial Represents a Rebuttable Coding Dispute, Not a Clear Coding Error

Per the payer's own policy basis underlying CO-4 denials — namely, the procedure code and modifier compatibility requirement — a denial under this remark code is appropriate only when a modifier is demonstrably incompatible with the billed procedure code. However, as the enclosed clinical documentation and billing guidelines reference establish, the modifier appended to CPT 71694 in this instance is not categorically excluded or incompatible. Rather, this situation presents a rebuttable coding dispute in which the supporting documentation resolves any ambiguity in favor of correct modifier use.

C. Medical Necessity Is Well-Supported

The diagnosis code J45.58 (unspecified asthma with acute exacerbation) directly supports the medical necessity of chest imaging on the date of service. The enclosed medical record excerpts corroborate the patient's acute clinical presentation and the ordering provider's clinical decision-making. There is no basis, clinical or administrative, to question the appropriateness of the imaging study itself.

D. Complete Supporting Documentation Is Enclosed

In support of this appeal, the following documents are enclosed for the payer's review:

  1. The procedure note from the date of service, April 20, 2026, documenting the CT chest study performed under CPT 71694.
  2. The modifier justification documentation or clinical attachment explaining the basis for the modifier appended to CPT 71694.
  3. Applicable CPT code 71694 billing guidelines and/or the relevant payer-specific coding reference supporting modifier compatibility.
  4. Medical record excerpts substantiating the patient's clinical presentation of acute asthma exacerbation (J45.58) and the clinical necessity of the modifier as applied.

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III. REQUESTED REMEDY

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

  1. Overturn the CO-4 denial associated with Claim TEST-CLAIM-00013;
  2. Reprocess the claim in full, recognizing the modifier appended to CPT 71694 as clinically justified and correctly applied; and
  3. Issue payment of the denied amount of $290.76 in accordance with the applicable Medicaid fee schedule.

We believe the enclosed documentation fully satisfies the payer's procedure code and modifier compatibility requirement and respectfully urge a prompt and favorable reconsideration of this claim.

Should additional information be required to complete the review of this appeal, please contact the provider's billing department at the address or telephone number on file.

Thank you for your time and consideration.

Respectfully submitted,

[Authorized Signature]
[Provider Name / Facility Name]
[NPI / Tax ID]
[Billing Department Contact Information]
[Date]