Appeal — TEST-CLAIM-00028

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00028
Internal Claim ID: 6b7766d0-3051-4022-a789-8db56801b6a8
Date of Service: April 25, 2026
Denial Date: May 14, 2026
Denied Amount: $1,239.67
Procedure Codes: CPT 38569, CPT 70952, CPT 43586
Diagnosis Codes: I10.77, F32.95
Appeal Deadline: June 13, 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-00028, issued by Synthetic Medicaid-TX on May 14, 2026. We respectfully request that this denial be overturned and that the claim be reprocessed for payment of the denied amount of $1,239.67.

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I. DENIAL REASON

The claim was denied under remark code CO-252, which states: "An attachment/other documentation is required to adjudicate this claim." The denial does not assert that the services rendered were non-covered, experimentally unproven, or medically unnecessary. Rather, it indicates a documentation deficiency that prevented the payer from completing adjudication.

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II. BASIS FOR APPEAL

We respectfully submit that the documentation necessary to satisfy the CO-252 requirement is enclosed with this appeal and is sufficient to support full adjudication and payment of the claim. The following key arguments support the reversal of this denial:

  • The CO-252 denial code reflects an administrative documentation deficiency, not a determination of non-coverage or lack of medical necessity; the enclosed records directly address that deficiency.

  • The procedures performed on April 25, 2026 — including CPT 38569 (lymph node excision), CPT 70952 (CT head/brain with contrast), and CPT 43586 (endoscopic ultrasound with fine needle aspiration) — are clinically supported by the enclosed operative report, imaging report, and physician notes from the date of service.

  • The enclosed clinical documentation and pathology report establish the medical necessity of the billed services in the context of the patient's documented diagnoses.

  • Any applicable prior authorization correspondence from Synthetic Medicaid-TX is enclosed and demonstrates that authorization requirements, to the extent applicable, were satisfied prior to the date of service.

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III. SUPPORTING DOCUMENTATION

In accordance with Synthetic Medicaid-TX's documentation submission requirements for CO-252 denials, the following documents are enclosed with this appeal:

  1. Operative Report — documenting the procedures performed on April 25, 2026, including CPT 38569 and CPT 43586.
  2. Imaging Report — documenting findings associated with CPT 70952 (CT head/brain with contrast).
  3. Pathology Report — supporting the clinical basis for the lymph node excision and endoscopic ultrasound with fine needle aspiration.
  4. Physician's Clinical Notes from the Date of Service — providing the clinical context and medical decision-making supporting all billed procedures.
  5. Letter of Medical Necessity — further establishing the clinical rationale for the services rendered.
  6. Prior Authorization Documentation (if applicable) — demonstrating any applicable pre-service authorization obtained from Synthetic Medicaid-TX.

Together, these documents satisfy the informational requirements outlined by the payer's documentation submission policy and provide a complete clinical record to support adjudication of the claim.

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IV. POLICY BASIS

Per Synthetic Medicaid-TX's applicable documentation submission requirement policy, a CO-252 denial is an administrative hold pending receipt of necessary attachments and does not constitute a final coverage or medical necessity determination. Accordingly, once the required documentation is received and reviewed, the payer's policy provides for reprocessing of the claim on its merits. The enclosed documentation is submitted for that purpose.

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V. REQUESTED REMEDY

We respectfully request that Synthetic Medicaid-TX:

  1. Accept the enclosed documentation as satisfying the requirements cited under CO-252.
  2. Reprocess Claim TEST-CLAIM-00028 in full.
  3. Issue payment of the denied amount of $1,239.67 in accordance with applicable Medicaid-TX fee schedules and contractual terms.

Should additional documentation or clarification be needed to complete adjudication, please contact our billing department at the information listed below at your earliest convenience to ensure timely resolution prior to the appeal deadline of June 13, 2026.

We appreciate your prompt attention to this matter and remain committed to resolving this issue collaboratively.

Respectfully submitted,

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

Enclosures:
  - Operative Report
  - Imaging Report (CT Head/Brain)
  - Pathology Report
  - Physician's Clinical Notes (Date of Service: April 25, 2026)
  - Letter of Medical Necessity
  - Prior Authorization Documentation (if applicable)