Appeal — TEST-CLAIM-00098

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00098
Internal Claim ID: a5a7ff22-ccb4-4b68-8923-eb77873978a3
Date of Service: March 26, 2026
Denial Date: May 29, 2026
Denial Code: CO-55
Procedure Codes: CPT 16265, CPT 95948
Diagnosis Codes: K21.15, N39.55
Appeal Deadline: September 26, 2026

Dear Synthetic Cigna Appeals and Grievances Department,

On behalf of [Facility Name], we hereby submit this formal first-level appeal contesting the denial of Claim TEST-CLAIM-00098 for services rendered on March 26, 2026. Synthetic Cigna issued a denial on May 29, 2026 under denial code CO-55, classifying CPT 16265 and CPT 95948 as experimental or investigational procedures. For the reasons set forth below, and as supported by the enclosed documentation, we respectfully request that this denial be overturned and that the claim be reprocessed for payment of the denied amount.

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I. BACKGROUND AND BASIS FOR DENIAL

On March 26, 2026, the patient received medically necessary treatment for documented diagnoses of gastroesophageal reflux disease (ICD-10: K21.15) and urinary incontinence (ICD-10: N39.55), billed under CPT codes 16265 and 95948, respectively. Synthetic Cigna denied these procedures under CO-55, asserting that the procedures are experimental or investigational in nature. The total denied amount attributable to this denial is $276.15.

[Facility Name] respectfully and strongly disagrees with this classification. The procedures performed are well-established, evidence-based interventions recognized in peer-reviewed clinical literature and applicable clinical guidelines as standard-of-care treatment for the patient's documented diagnoses. The experimental/investigational classification applied by Synthetic Cigna is not supported by the current body of medical evidence and does not accurately reflect the clinical or regulatory status of the procedures at issue.

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II. GROUNDS FOR APPEAL

A. The Procedures Are Not Experimental or Investigational

The payer's denial rests entirely on the assertion that CPT 16265 and CPT 95948 meet the definition of experimental or investigational procedures under Synthetic Cigna's applicable coverage policy. This assertion is factually and clinically incorrect. As demonstrated by the enclosed supporting documentation, both procedures:

  1. Are supported by peer-reviewed clinical literature and established clinical practice guidelines as appropriate, effective, and medically necessary treatments for the patient's diagnoses of GERD (K21.15) and urinary incontinence (N39.55);
  2. Have been evaluated in published clinical studies confirming their non-experimental status and clinical efficacy for the indications at issue; and
  3. Where applicable, carry FDA clearance or approval, further confirming that these procedures have undergone the rigorous review necessary to establish their safety and effectiveness.

Because the procedures do not satisfy the payer's own criteria for experimental or investigational classification — namely, that a procedure lacks sufficient clinical evidence, peer-reviewed support, or regulatory approval — the basis for the CO-55 denial is without merit and should be reversed.

B. Medical Necessity Is Clearly Documented

The enclosed letter of medical necessity from the treating physician establishes that CPT 16265 and CPT 95948 were clinically indicated, appropriate, and necessary for this patient given their documented diagnoses. The treating physician's clinical judgment, supported by the patient's medical history and condition, confirms that these procedures represent the standard-of-care approach for managing GERD and urinary incontinence as presented in this case. The enclosed operative report and procedural documentation further corroborate that the services were performed as billed and in accordance with accepted clinical standards.

C. The Payer's Experimental/Investigational Exclusion Does Not Apply

Under Synthetic Cigna's experimental/investigational exclusion policy, a procedure may be excluded only when it lacks sufficient clinical evidence or peer-reviewed support to establish its safety and effectiveness for the condition being treated. The enclosed peer-reviewed clinical literature and evidence-based guidelines demonstrate conclusively that CPT 16265 and CPT 95948 have met and exceeded the evidentiary thresholds required to be considered standard-of-care treatments. Accordingly, the exclusion cited under CO-55 is inapplicable to this claim, and continued denial on this basis would be inconsistent with the payer's own policy criteria.

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III. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, the following documents are enclosed for the reviewer's consideration:

  1. Letter of medical necessity from the treating physician;
  2. Operative report and procedural documentation for the services rendered on March 26, 2026;
  3. Peer-reviewed clinical guidelines and published clinical literature supporting the medical necessity and non-experimental status of CPT 16265 and CPT 95948 for the diagnosed conditions;
  4. FDA approval or clearance status documentation (where applicable) for the procedures at issue; and
  5. Any payer policy documentation or correspondence referencing the experimental/investigational classification applied to these procedures.

We respectfully request that the reviewing clinician and appeals specialist carefully consider the totality of the enclosed evidence prior to rendering a determination.

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IV. REQUESTED REMEDY

Based on the foregoing, [Facility Name] respectfully requests that Synthetic Cigna:

  1. Overturn the denial issued under CO-55 for Claim TEST-CLAIM-00098;
  2. Reprocess the claim in full; and
  3. Issue payment of the denied amount of $276.15 in accordance with the patient's applicable benefit plan and the contracted rate.

Should additional clinical information or documentation be required to complete the review of this appeal, please contact [Facility Name] Appeals Department at [Phone Number] or [Email Address] at your earliest convenience. We are committed to working collaboratively with Synthetic Cigna to resolve this matter promptly and in the best interest of the patient.

This appeal is submitted within the applicable appeal deadline of September 26, 2026, and in accordance with Synthetic Cigna's appeals and grievance procedures.

Respectfully submitted,

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

Enclosures:
  - Letter of Medical Necessity
  - Operative Report / Procedural Documentation
  - Peer-Reviewed Clinical Literature and Guidelines
  - FDA Approval/Clearance Documentation (if applicable)
  - Payer Policy Documentation (if available)