Appeal — TEST-CLAIM-00058

Date: [Date of Submission]

Synthetic UHC
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00058
Internal Claim Reference: 6498c113-2b77-4e02-adb2-ed1349e71b8c
Payer: Synthetic UHC
Service Date: January 24, 2026
Procedure Code: CPT 71385
Diagnosis Code: ICD-10 I10.96
Denial Date: April 9, 2026
Denied Amount: $7,545.36
Appeal Deadline: July 8, 2026

Dear Synthetic UHC Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of the submitting facility regarding the denial of the above-referenced claim. On April 9, 2026, Synthetic UHC issued a denial citing remark code CO-55 — Procedure/treatment is deemed experimental/investigational by the payer — for CPT 71385 (cardiac magnetic resonance imaging), performed on January 24, 2026, in connection with a diagnosis of hypertensive chronic kidney disease (ICD-10 I10.96). The facility respectfully contests this denial in its entirety and requests that the claim be reprocessed and payment of the denied amount of $7,545.36 be issued.

I. GROUNDS FOR APPEAL

The denial under CO-55 is not supported by the clinical, regulatory, or policy record applicable to CPT 71385. Cardiac magnetic resonance (CMR) imaging is an FDA-cleared diagnostic modality that has achieved broad acceptance within the medical community as a standard-of-care tool for evaluating structural and functional cardiac involvement in patients with systemic conditions, including hypertensive chronic kidney disease. The payer's classification of this procedure as experimental or investigational is inconsistent with the established evidentiary and regulatory status of CMR imaging and is therefore subject to reversal on appeal.

Specifically, the following bases support overturning the denial:

1. FDA Clearance: CPT 71385 represents cardiac MRI, a modality that has received FDA clearance and is widely utilized in clinical practice. It does not meet the definition of "experimental" or "investigational" under standard payer criteria, which typically require that a service lack sufficient clinical evidence, regulatory approval, or general acceptance by the medical community. As documented in the enclosed FDA approval documentation or clearance status for CPT 71385, this procedure satisfies all requisite standards.

2. Established Medical Necessity: The treating physician has attested to the clinical necessity of CMR imaging for this patient's evaluation of cardiac involvement associated with hypertensive chronic kidney disease (I10.96). Hypertension is a well-documented cause of both renal and cardiac end-organ damage, and non-invasive cardiac imaging is integral to the comprehensive management of such patients. The enclosed letter of medical necessity from the treating physician details the specific clinical indications that warranted this study.

3. Peer-Reviewed Clinical Evidence and Published Guidelines: The clinical evidence base supporting the use of cardiac MRI in patients with hypertensive disease and associated chronic kidney disease is robust. Peer-reviewed literature and published clinical guidelines from recognized professional organizations endorse CMR imaging as an appropriate and evidence-based diagnostic tool in this clinical context. The enclosed clinical evidence and peer-reviewed literature, as well as the enclosed published clinical guidelines endorsing the procedure for the patient's condition, collectively demonstrate that CPT 71385 is consistent with accepted standards of care.

4. Payer Policy Inconsistency: A review of Synthetic UHC's own coverage framework reveals that the experimental/investigational exclusion is intended to apply to procedures lacking FDA clearance, peer-reviewed support, or professional consensus — criteria that CPT 71385 does not meet. The enclosed copy of the payer's own coverage policy or medical policy on this procedure is offered to demonstrate that the CO-55 designation was applied in error. The facility urges the reviewer to reconcile the denial rationale with the payer's stated coverage standards.

II. SUPPORTING DOCUMENTATION

The following documents are enclosed in support of this appeal:

- Letter of medical necessity from the treating physician
- Clinical evidence and peer-reviewed literature supporting CPT 71385 for ICD-10 I10.96
- FDA approval documentation or clearance status for CPT 71385
- Prior authorization request with clinical justification
- Medical records demonstrating the clinical indication and basis for imaging
- Payer's own coverage policy or medical policy on this procedure
- Published clinical guidelines endorsing cardiac MRI for the patient's condition

III. REQUESTED REMEDY

The facility respectfully requests that Synthetic UHC:

1. Overturn the CO-55 denial for claim TEST-CLAIM-00058 in its entirety;
2. Reprocess the claim in accordance with the applicable coverage terms; and
3. Issue payment of the denied amount of $7,545.36 to the facility.

If additional clinical information or documentation is required to complete this review, please contact the facility's appeals coordinator at the address or telephone number listed above at your earliest convenience, and well in advance of the appeal deadline of July 8, 2026.

The facility appreciates Synthetic UHC's prompt and thorough review of this matter. We are confident that upon consideration of the enclosed documentation, the reviewer will find that CPT 71385 was a covered, medically necessary, and clinically appropriate service and that the CO-55 denial designation is not warranted.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Telephone Number]
[Fax Number]
[Date]