Appeal — TEST-CLAIM-00074

Date: [Date of Submission]

Synthetic UHC
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00074
Service Date: April 14, 2026
Denial Date: May 4, 2026
Denied Amount: $3,291.12
Total Billed Amount: $4,311.38
Procedure Codes: CPT 89570, 67939
Diagnosis Codes: K21.27, G43.14

Dear Synthetic UHC Appeals Department,

This letter constitutes a formal appeal on behalf of [Hospital/Facility Name] regarding the denial of Claim Number TEST-CLAIM-00074, dated May 4, 2026. The claim was denied under remark code CO-4, citing inconsistency between the procedure code(s) billed and the modifier(s) applied. After thorough review of the clinical documentation, CPT code descriptors, and applicable coding guidelines, we respectfully assert that the denial is not supported and request that the claim be overturned and reprocessed for payment of the denied amount of $3,291.12.

I. DENIAL REASON AND BASIS FOR APPEAL

Synthetic UHC issued a CO-4 denial asserting that the modifier applied to the procedure code(s) billed — CPT 89570 and 67939 — is inconsistent with the CPT code definition. We respectfully disagree with this determination. The modifier in question was applied in direct accordance with AMA CPT coding guidelines and accurately reflects the clinical work performed on the date of service. The denial represents a coding dispute that is fully addressable through the supporting clinical and coding documentation enclosed with this appeal.

II. CLINICAL AND CODING JUSTIFICATION

The procedures performed on April 14, 2026, are thoroughly documented in the enclosed operative report and procedure note, which provide a detailed account of the clinical work performed corresponding to CPT codes 89570 and 67939. The diagnoses of record — GERD (K21.27) and migraine (G43.14) — are supported by the enclosed medical record excerpts and are consistent with the procedures billed.

The modifier applied to the procedure code(s) accurately reflects the nature of the service rendered. Specifically:

  • The enclosed CPT code descriptor reference and clinical correlation document demonstrate that the modifier is appropriate within the definition and scope of the CPT code(s) billed and is not excluded, restricted, or otherwise inconsistent per the AMA's published coding guidance.

  • The enclosed modifier usage documentation and coding guidance further substantiate that the modifier was applied correctly based on the clinical circumstances present on the date of service.

  • The enclosed operative report confirms the procedural work performed and supports both the selection of the procedure codes and the modifier applied, leaving no clinical or technical basis for the CO-4 denial.

III. APPLICABLE PAYER POLICY

We acknowledge Synthetic UHC's procedure code and modifier compatibility requirement, under which a modifier must be consistent with the CPT code definition to which it is applied. However, as the enclosed documentation demonstrates, this requirement is satisfied in full. The operative report, procedure note, CPT descriptor reference, and modifier usage documentation collectively establish that the modifier is clinically and technically compatible with the billed procedure codes. Where clinical documentation supports the modifier's appropriateness and the modifier does not alter or contradict the CPT code descriptor, a CO-4 denial is not warranted and should be overturned upon appeal.

IV. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

  1. Operative report / procedure note for the date of service (April 14, 2026)
  2. Modifier usage documentation and applicable coding guidance
  3. CPT code descriptor reference and clinical correlation analysis
  4. Medical record excerpts supporting the procedure codes and diagnoses billed

V. REQUESTED REMEDY

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

  1. Overturn the CO-4 denial on Claim Number TEST-CLAIM-00074;
  2. Reprocess the claim in accordance with the applicable fee schedule and plan benefits; and
  3. Issue payment of the denied amount of $3,291.12.

This appeal is being submitted in advance of the appeal deadline of August 2, 2026. Should Synthetic UHC require any additional information or clarification in support of this appeal, please contact the undersigned at [Contact Name, Phone Number, and/or Email Address] at your earliest convenience.

We appreciate your prompt attention to this matter and look forward to a favorable resolution.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Date]