Appeal — TEST-CLAIM-00053

Date: [Insert Date of Submission]

Via: [Insert Submission Method — Certified Mail / Payer Portal]

Synthetic Aetna
Appeals & Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00053
Internal Claim Reference: dbeec051-39ae-4454-8e11-1857795e3d8e
Date of Service: January 2, 2026
Denial Date: March 2, 2026
Denied Amount: $1,597.29
Appeal Deadline: August 29, 2026

Dear Synthetic Aetna Appeals Department,

On behalf of the submitting facility and treating providers, we respectfully submit this formal appeal contesting the denial of Claim TEST-CLAIM-00053, issued by Synthetic Aetna on March 2, 2026. The claim was denied under reason code CO-16: "Claim/service lacks information or has submission/billing error(s)," resulting in a denied amount of $1,597.29 against a total billed amount of $2,377.57 for services rendered on January 2, 2026.

We respectfully request that Synthetic Aetna overturn this denial, reprocess the claim in full, and remit payment of the denied amount of $1,597.29.

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I. NATURE OF THE DENIAL

The CO-16 denial code indicates that the claim was rejected on the basis of missing information or a submission/billing error. Importantly, this denial does not reflect a determination that the services were not covered, not medically necessary, or otherwise excluded under the member's benefit plan. Rather, it reflects a technical or administrative deficiency in the original claim submission — a deficiency that is fully correctable and which we are addressing through this appeal.

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II. BASIS FOR APPEAL

Upon internal review, our billing and coding team identified and corrected the submission deficiency that gave rise to the CO-16 denial. A comprehensive corrected claim has been prepared and is enclosed with this appeal, along with the full complement of supporting documentation. The billed services — CPT 99364 (established patient evaluation and management), CPT 33600 (cardiac procedure), and CPT 32280 (thoracic procedure), submitted under diagnosis code E11.78 (Type 2 diabetes with hypoglycemia with coma) — were all medically necessary, properly performed, and appropriately coded.

The following key arguments support the reversal of this denial:

  • The CO-16 denial reflects a correctable submission error, not a coverage or medical necessity exclusion, and payer policy expressly contemplates reprocessing upon receipt of a corrected claim with complete information.

  • The enclosed corrected claim submission provides all previously missing or incomplete fields, directly curing the deficiency identified under Synthetic Aetna's claim submission and billing accuracy requirements.

  • The enclosed operative report and evaluation and management documentation confirm that CPT codes 99364, 33600, and 32280 were properly performed, accurately coded, and clinically supported on the date of service.

  • The enclosed coding worksheet and audit memo identify the specific original submission error, detail the correction applied, and demonstrate that all billed procedures are correctly represented in the resubmitted claim.

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III. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

  1. Corrected claim submission with all required fields completed
  2. Itemized billing statement with line-item descriptions for all billed procedures
  3. Operative report supporting CPT codes 33600 and 32280
  4. Progress notes and evaluation and management documentation supporting CPT code 99364
  5. Coding worksheet and audit memo identifying and correcting the original submission error
  6. Medical records supporting medical necessity for all billed procedures under diagnosis code E11.78

Together, these documents establish that the original denial was the result of a technical submission deficiency that has been fully remediated, and that all billed services are covered, medically necessary, and properly documented.

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IV. POLICY BASIS AND REMEDY REQUESTED

Pursuant to Synthetic Aetna's claim submission and billing accuracy requirements, a corrected claim submission that cures the identified deficiency — accompanied by the operative reports, E/M documentation, and coding audit memo described above — is sufficient to establish proper entitlement to payment for the billed services. No coverage exclusion, medical necessity denial, or other substantive basis for non-payment has been identified or asserted.

Accordingly, we respectfully request that Synthetic Aetna:

  1. Accept this formal appeal and the enclosed corrected claim and supporting documentation;
  2. Reprocess Claim TEST-CLAIM-00053 in its entirety; and
  3. Issue payment of the denied amount of $1,597.29 in accordance with the applicable contract terms and fee schedule.

Should additional information be required to resolve this matter, please contact the appropriate facility representative at the contact information below. We are committed to cooperating fully to facilitate prompt resolution.

Thank you for your prompt attention to this appeal.

Respectfully submitted,

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

Enclosures: As listed in Section III above