Appeal — TEST-CLAIM-00086

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic UHC

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00086
Internal Claim ID: 87bb2c13-9d23-4dfd-8ab3-00ecd67515fc
Date of Service: January 16, 2026
Denial Date: March 25, 2026
Denied Amount: $1,559.47
Procedure Code(s): CPT 54791
Diagnosis Code(s): J45.28, I10.19

Dear Appeals and Grievances Department,

On behalf of the treating facility, we are submitting this formal written appeal in response to the denial of Claim TEST-CLAIM-00086, issued by Synthetic UHC on March 25, 2026. The claim was denied under remark code CO-4, citing that the procedure code is inconsistent with the modifier used. We respectfully contest this determination and request that the claim be reprocessed and payment of the denied amount of $1,559.47 be issued in full.

I. NATURE OF THE DENIAL

The payer issued a CO-4 denial asserting an incompatibility between CPT code 54791 and the modifier applied at the time of claim submission for services rendered on January 16, 2026. The denied portion represents $1,559.47 of the $3,021.02 total billed amount. It is the facility's position that this denial is incorrect and that the modifier as submitted is both clinically and coding-appropriate for the procedure performed.

II. BASIS FOR APPEAL

The facility respectfully submits that the CO-4 denial is not supported by the operative and coding record associated with this claim. The following arguments form the basis of this appeal:

1. The Modifier Is Clinically Appropriate for CPT 54791 as Performed

The enclosed operative report provides a detailed account of the procedure performed on January 16, 2026, including the specific clinical circumstances that necessitated the use of the modifier in question. The operative documentation clearly reflects that the modifier accurately describes the nature of the service as delivered and is not in conflict with CPT 54791.

2. CPT Coding Guidance Supports Modifier Compatibility

The enclosed CPT coding reference and medical billing guidance demonstrate that the modifier applied is recognized as appropriate for use with CPT 54791 under the relevant coding conventions. The payer's finding of incompatibility is directly contradicted by established coding authority, which confirms that the modifier and procedure code combination is permissible and correctly reflects the clinical scenario.

3. Claim Submission Documentation Confirms Accurate Coding

The enclosed claim submission documentation establishes the specific modifier that was applied and demonstrates that the submission was consistent with the operative findings and applicable coding standards. There is no coding error on the face of the claim.

4. The Denial Is Contestable Under the Payer's Own Policy Standard

Synthetic UHC's procedure code and modifier compatibility requirement provides that a CO-4 denial is appropriate only where a genuine inconsistency exists between a procedure code and its associated modifier. Where, as here, the operative report and CPT coding guidance affirmatively support the modifier's appropriateness, the payer's incompatibility determination lacks a valid basis and the denial should be overturned.

III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

- Operative report with procedure details and modifier justification
- Claim submission documentation showing the modifier code applied
- CPT coding reference or medical billing guidance supporting modifier usage with CPT 54791
- Clinical documentation supporting the medical necessity of the procedure as billed

IV. REQUESTED REMEDY

The facility respectfully requests that Synthetic UHC:

1. Overturn the CO-4 denial issued on March 25, 2026, with respect to Claim TEST-CLAIM-00086;
2. Reprocess the claim in full recognizing the modifier as submitted; and
3. Issue payment of the denied amount of $1,559.47 in accordance with the applicable contracted rate and plan terms.

This appeal is being submitted in advance of the appeal deadline of June 23, 2026. Should additional information be required to resolve this matter, please contact the undersigned at your earliest convenience. We appreciate your prompt attention to this dispute and remain committed to a timely and cooperative resolution.

Respectfully submitted,

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