Appeal — TEST-CLAIM-00019

Date: [Letter Date]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Reference Number: TEST-CLAIM-00019
Internal Claim ID: 6e805404-05d9-4063-b928-fc14c512ddc2
Service Date: October 23, 2025
Denial Date: December 18, 2025
Denied Amount: $1,423.50
Procedure Code(s): CPT 13201
Diagnosis Code(s): J45.60

Dear Synthetic Cigna Appeals and Grievances Department,

On behalf of [Hospital/Facility Name], we are submitting this formal written appeal in response to the denial of Claim TEST-CLAIM-00019, issued on December 18, 2025. The claim was denied under CO-198 (Precertification/Authorization Exceeded) for services rendered on October 23, 2025, resulting in a denied amount of $1,423.50. We respectfully contest this denial and request that the claim be reprocessed and paid in full, as the services provided were performed within the scope and limits of the prior authorization issued for this patient.

---

I. BACKGROUND AND BASIS FOR DENIAL

Synthetic Cigna denied the above-referenced claim under the CO-198 adjustment reason code, asserting that the precertification or authorization obtained was exceeded by the services rendered. The procedure at issue is CPT 13201 (repair of superficial wounds), billed in connection with diagnosis J45.60 (unspecified asthma with acute exacerbation) on the date of service, October 23, 2025.

[Hospital/Facility Name] disputes this denial in its entirety. The services rendered on October 23, 2025 were performed within the authorized procedure type, clinical scope, and approved parameters reflected in the prior authorization on file. The denial therefore does not accurately reflect the correspondence between the services delivered and the authorization granted.

---

II. GROUNDS FOR APPEAL

A. The Prior Authorization Was Valid and Applicable to the Services Rendered

Prior to the date of service, [Hospital/Facility Name] obtained a prior authorization from Synthetic Cigna for the treatment provided. As documented in the enclosed prior authorization approval letter, CPT 13201 was an authorized procedure for this patient. The services were delivered on October 23, 2025, consistent with the authorization's approved procedure type and clinical parameters. No evidence exists that the services exceeded the authorized limits in terms of procedure code, units, or clinical scope.

B. Clinical Documentation Confirms Services Were Within Authorized Parameters

The enclosed operative report and procedure documentation for CPT 13201 confirm that the procedure was performed precisely as authorized. The enclosed clinical notes and medical records further substantiate that the services rendered were medically necessary, clinically appropriate, and directly aligned with the treatment plan supporting the authorization. Nothing in the clinical record indicates a departure from the scope of the approved precertification.

C. The Payer's CO-198 Denial Is Unsupported by the Authorization Record

Under Synthetic Cigna's prior authorization scope and limits requirement, a CO-198 denial is warranted only when services rendered exceed the scope, quantity, or procedure type approved under the precertification. In this instance, the billed services reflect CPT 13201 as authorized — there is no evidence of excess units, an unauthorized procedure, or an expansion of clinical scope beyond what was approved. The denial therefore lacks a factual basis under the applicable policy standard.

D. The Itemized Billing Statement Is Consistent With the Authorization

The enclosed itemized billing statement demonstrates that the billed service components correspond directly to CPT 13201 as authorized. The billed amount of $1,646.44, with $1,423.50 currently denied, reflects charges aligned with the single authorized procedure. There is no discrepancy between the authorization on file and the claim as submitted.

---

III. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, the following documents are enclosed for your review:

1. Prior authorization approval letter — confirming authorization for CPT 13201 on the applicable date of service.
2. Operative report and procedure documentation for CPT 13201 — confirming the procedure was performed as authorized.
3. Medical records demonstrating medical necessity for the authorized procedure.
4. Clinical notes demonstrating the procedure was within authorized parameters.
5. Itemized billing statement showing service components consistent with the authorization.
6. Correspondence with payer regarding authorization limits or scope (if applicable).

---

IV. REQUESTED REMEDY

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

1. Overturn the CO-198 denial issued on December 18, 2025 for Claim TEST-CLAIM-00019;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $1,423.50 in accordance with the applicable contract terms and the prior authorization on file.

This appeal is being submitted in advance of the applicable appeal deadline of April 17, 2026. Should additional information or clarification be needed to resolve this matter, please contact [Hospital Contact Name] at [Phone Number] or [Email Address].

We appreciate your prompt attention to this appeal and look forward to a timely resolution.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Date]

Enclosures: As listed in Section III above