Appeal — TEST-CLAIM-00085

Date: [Appeal Submission Date]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00085
Service Date: January 6, 2026
Procedure Code(s): CPT 87993
Diagnosis Code(s): ICD-10 K21.71 (Gastroesophageal Reflux Disease with Esophagitis)
Denial Date: April 4, 2026
Denied Amount: $970.95
Appeal Deadline: August 2, 2026

Dear Synthetic Cigna Appeals Department,

This letter constitutes a formal written appeal on behalf of the treating facility regarding the denial of Claim Number TEST-CLAIM-00085, submitted to Synthetic Cigna for services rendered on January 6, 2026. The claim was denied under adjustment reason code CO-55, with the payer classifying CPT 87993 (esophageal reflux/function testing) as experimental or investigational. We respectfully contest this determination and request that the claim be reconsidered, reprocessed, and paid in full for the denied amount of $970.95.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

Synthetic Cigna issued a denial under CO-55, asserting that the procedure billed under CPT 87993 is experimental or investigational in nature. The facility and treating physician strongly disagree with this classification. CPT 87993 represents an established, widely accepted diagnostic procedure used in the evaluation of gastroesophageal reflux disease (GERD) with esophagitis — a diagnosis confirmed for this patient under ICD-10 code K21.71. The application of an experimental/investigational exclusion to this procedure is clinically unsupported and inconsistent with current standards of care.

The denial should be overturned on the following grounds:

  • CPT 87993, as applied in the evaluation of GERD with esophagitis (K21.71), is a recognized, guideline-supported diagnostic tool that does not meet the clinical or regulatory criteria for classification as experimental or investigational.

  • Peer-reviewed clinical literature and published gastroenterological guidelines substantiate the use of esophageal reflux testing as a standard-of-care diagnostic approach for the confirmed diagnosis presented.

  • The procedure has received applicable FDA approval or clearance, further confirming its accepted clinical status and undermining any basis for an experimental/investigational designation.

  • The treating physician has documented clear clinical necessity for the procedure given the patient's specific presentation with GERD and esophagitis, as detailed in the enclosed letter of medical necessity.

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II. SUPPORTING DOCUMENTATION

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

  1. Letter of Medical Necessity — A letter from the treating physician documenting the clinical rationale for ordering CPT 87993 in the context of the patient's confirmed diagnosis of GERD with esophagitis (K21.71), affirming that the procedure was medically appropriate and necessary.

  2. Peer-Reviewed Clinical Guidelines and Published Literature — Evidence from recognized clinical and professional society guidelines, as well as relevant peer-reviewed literature, demonstrating that esophageal reflux testing is an accepted, standard-of-care diagnostic procedure for the evaluation and management of GERD with esophagitis.

  3. FDA Approval/Clearance Documentation — Documentation confirming the FDA approval or clearance status of the procedure and associated technology, establishing that the service does not meet the regulatory threshold for experimental or investigational classification.

  4. Prior Authorization Request and Clinical Rationale — Documentation of any prior authorization submission and the accompanying clinical rationale provided to the payer, further substantiating the medical necessity determination made by the treating physician.

  5. Clinical Evidence of Standard-of-Care Status — Additional clinical evidence demonstrating that CPT 87993 is routinely utilized in the diagnosis and management of conditions such as K21.71, and is not regarded as experimental or investigational by the broader medical community.

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III. POLICY ANALYSIS AND APPLICABLE PAYER RULE

Synthetic Cigna's application of its experimental/investigational exclusion policy to this claim is not clinically warranted. The payer's own policy framework for applying this exclusion requires that a procedure lack sufficient clinical evidence to support its safety, efficacy, or acceptance within the medical community. As demonstrated by the enclosed supporting documentation, CPT 87993 for the diagnosis of GERD with esophagitis does not satisfy these criteria. The procedure is guideline-endorsed, FDA-cleared, and widely performed as a diagnostic standard in clinical practice.

Where a procedure is supported by published clinical guidelines, has achieved FDA approval or clearance, and is recognized by the relevant physician community as appropriate for the stated diagnosis, a payer's experimental/investigational exclusion lacks a defensible clinical foundation. Applying CO-55 under these circumstances constitutes an improper denial and is inconsistent with the payer's own evidentiary standards for such exclusions.

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IV. REQUESTED REMEDY

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

  1. Overturn the CO-55 denial applied to Claim Number TEST-CLAIM-00085;
  2. Reprocess the claim in full in accordance with the applicable plan benefits and contracted rates; and
  3. Issue payment for the denied amount of $970.95 promptly upon completion of reprocessing.

Should additional information be required to complete this review, please contact our appeals team at the address or phone number listed below. We ask that this appeal be reviewed by a qualified clinical reviewer with relevant expertise in gastroenterology or diagnostic testing, as required by applicable law and plan policy.

Thank you for your prompt attention to this matter. We trust that upon review of the enclosed documentation, Synthetic Cigna will agree that the denial of CPT 87993 for ICD-10 K21.71 on January 6, 2026, was issued in error and that payment of the denied amount is warranted.

Respectfully submitted,

[Facility Name]
[Appeals Representative Name and Title]
[Address]
[Phone Number]
[Fax Number]
[Reference: Claim TEST-CLAIM-00085]

Enclosures:
  - Letter of Medical Necessity
  - Peer-Reviewed Clinical Guidelines and Published Literature
  - FDA Approval/Clearance Documentation
  - Prior Authorization Request and Clinical Rationale
  - Clinical Evidence of Standard-of-Care Status