Appeal — TEST-CLAIM-00006

Date: [Date of Submission]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00006
Service Date: November 18, 2025
Denial Date: December 25, 2025
Denied Amount: $7,297.01
Procedure Codes: CPT 42271, 85880, 87924
Diagnosis Code: ICD-10 F32.10
Appeal Deadline: June 23, 2026

Dear Synthetic Aetna Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the above-referenced claim (TEST-CLAIM-00006), which was denied on December 25, 2025, under denial code CO-55. The payer has classified the procedures billed under CPT codes 42271, 85880, and 87924 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 $7,297.01.

I. DENIAL REASON AND BASIS FOR APPEAL

Synthetic Aetna denied the above-referenced claim under CO-55, asserting that the procedures rendered on November 18, 2025, are experimental or investigational in nature. The facility firmly disagrees with this classification. The procedures performed — billed under CPT codes 42271, 85880, and 87924 — represent established, widely accepted, standard-of-care interventions for the patient's diagnosed condition of Major Depressive Disorder, single episode, moderate (ICD-10 F32.10). The denial is inconsistent with current clinical evidence and applicable policy standards governing the distinction between experimental procedures and accepted medical practice.

II. CLINICAL AND EVIDENTIARY BASIS

The following documentation is enclosed in support of this appeal and collectively demonstrates that the disputed procedures are neither experimental nor investigational:

1. Peer-Reviewed Clinical Guidelines and Position Statements: The enclosed peer-reviewed clinical guidelines and professional society position statements establish that the procedures billed under CPT codes 42271, 85880, and 87924 are recognized as standard-of-care treatment for the patient's diagnosed condition. These guidelines reflect the current consensus of the medical community and confirm that these procedures have moved well beyond the investigational stage.

2. Published Clinical Evidence: The enclosed published clinical literature documents the demonstrated efficacy and safety of these procedures across relevant patient populations. This body of evidence further refutes any characterization of these services as investigational.

3. Letter of Medical Necessity: The enclosed letter of medical necessity from the treating physician provides a detailed clinical rationale for the selection and administration of these procedures in the context of the patient's confirmed diagnosis of F32.10. The treating physician attests that the procedures were medically necessary, clinically indicated, and consistent with accepted standards of care.

4. Operative Report and Procedure Documentation: The enclosed operative report and procedure documentation confirm that the services were rendered as billed, are accurately coded, and were performed in accordance with established clinical protocols.

5. FDA Approval or Clearance Documentation (if applicable): Where applicable, enclosed documentation reflects regulatory approval or clearance supporting the use of the relevant procedure(s) in clinical practice.

6. Comparative Outcome Data: The enclosed comparative outcome data further demonstrates that these procedures are no longer investigational and are widely utilized in clinical practice with documented patient benefit.

III. POLICY ANALYSIS

Synthetic Aetna's own policy language governing the experimental/investigational exclusion requires that a procedure be evaluated against current peer-reviewed literature, clinical practice guidelines, and the prevailing standard of care before being classified as experimental or investigational. When such an evaluation is applied to CPT codes 42271, 85880, and 87924 as administered for ICD-10 diagnosis F32.10, the evidence clearly supports their classification as established, standard-of-care procedures. The payer's application of the CO-55 denial code in this instance does not appear to reflect a proper or current assessment of the available clinical evidence and is therefore inconsistent with the payer's own policy criteria for the experimental/investigational exclusion.

IV. REQUESTED REMEDY

Based on the clinical documentation, published evidence, and policy analysis presented herein, we respectfully request that Synthetic Aetna:

1. Overturn the CO-55 denial determination for claim TEST-CLAIM-00006;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $7,297.01 in accordance with the patient's applicable plan benefits.

Should additional information be required to support this appeal, please contact our facility's billing and appeals department at the contact information provided below. We are prepared to supplement this record with any further documentation that may assist in the timely resolution of this matter.

Thank you for your prompt attention to this appeal. We trust that upon review of the enclosed documentation, Synthetic Aetna will agree that the denial of claim TEST-CLAIM-00006 is not supported by current clinical evidence or applicable policy standards, and that payment will be issued accordingly.

Respectfully submitted,

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

Enclosures:
- Peer-reviewed clinical guidelines and position statements
- Published clinical evidence of efficacy and safety
- Letter of medical necessity from treating physician
- Operative report and procedure documentation
- FDA approval or clearance documentation (if applicable)
- Comparative outcome data
- Copy of original claim (TEST-CLAIM-00006)