Appeal — TEST-CLAIM-00069

Date: [Date of Submission]

Appeal and Grievance Department
Synthetic Cigna
[Payer Address]

Re:    Formal Appeal of Medical Necessity Denial
       Claim Number: TEST-CLAIM-00069
       Payer: Synthetic Cigna
       Date of Service: December 26, 2025
       Denial Date: March 1, 2026
       Denied Amount: $1,546.46
       Total Billed Amount: $2,582.88

Dear Appeals and Grievance Review Committee,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] (hereinafter "the Facility") regarding the denial of Claim No. TEST-CLAIM-00069. Synthetic Cigna issued a CO-50 denial on March 1, 2026, asserting that the endoscopic and related procedures performed on December 26, 2025, were not deemed medically necessary. For the reasons set forth below, and as supported by the enclosed clinical documentation, the Facility respectfully requests that Synthetic Cigna overturn this denial, reprocess Claim No. TEST-CLAIM-00069 in full, and remit payment of the denied amount of $1,546.46.

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I. BACKGROUND AND NATURE OF THE DENIAL

On December 26, 2025, the Facility provided endoscopic and related services to the patient, including procedures billed under CPT 43408 (Endoscopic Retrograde Cholangiopancreatography, ERCP), CPT 59060, and CPT 30006. The primary diagnosis supporting these services was E11.11 (Type 2 Diabetes Mellitus with Hypoglycemia), which, in conjunction with the patient's clinical presentation, indicated pancreatic and/or biliary involvement requiring endoscopic intervention.

By correspondence dated March 1, 2026, Synthetic Cigna denied $1,546.46 of the $2,582.88 billed, citing denial code CO-50 — a determination that the services were not medically necessary under the payer's medical necessity criteria. The Facility respectfully disagrees with this determination and submits this appeal with supporting clinical documentation demonstrating that the denied services were medically necessary, consistent with standard-of-care guidelines, and fully supported by the treating physician's clinical judgment.

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II. BASIS FOR APPEAL

A. The Procedures Were Clinically Indicated by the Patient's Documented Diagnosis

The patient presented with a documented diagnosis of Type 2 Diabetes Mellitus with Hypoglycemia (ICD-10: E11.11), a condition well-recognized in the clinical literature to be associated with pancreatic and biliary complications. The treating physician determined, based on the patient's medical history and clinical presentation, that endoscopic evaluation and intervention via ERCP (CPT 43408) and the associated procedures were necessary to evaluate and address the underlying pancreatic or biliary pathology contributing to the patient's condition. As reflected in the enclosed clinical documentation and operative/procedure notes, the procedures performed were directly responsive to clinically documented findings and were consistent with the standard of care for patients presenting with this diagnosis.

B. The Letter of Medical Necessity Establishes Clinical Justification

The enclosed letter of medical necessity, authored by the treating physician, provides a detailed clinical rationale for the procedures performed on December 26, 2025. The letter documents the physician's clinical assessment, the patient's presenting symptoms and diagnostic findings, and the medical basis for proceeding with endoscopic intervention. The treating physician's judgment that these services were necessary is entitled to substantial weight in any medical necessity determination. Synthetic Cigna's CO-50 denial does not appear to account for, or adequately consider, this documented physician judgment.

C. The Procedures Are Supported by Peer-Reviewed Clinical Guidelines

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely accepted and evidence-based intervention for the evaluation and treatment of pancreatic and biliary pathology. The enclosed peer-reviewed clinical guidelines on the endoscopic management of pancreatic and biliary conditions confirm that the use of ERCP in patients presenting with the clinical profile reflected in this claim is consistent with accepted standards of medical practice. The payer's determination that the services lacked medical necessity is inconsistent with the weight of current clinical evidence.

D. The Denial Is Inconsistent with Synthetic Cigna's Own Medical Necessity Criteria

Synthetic Cigna's medical necessity criteria require that covered services be consistent with the diagnosis, appropriate in terms of type, frequency, and duration, and in accordance with generally accepted standards of medical practice. As demonstrated by the enclosed documentation — including the treating physician's letter of medical necessity, the operative and procedure notes for CPT 43408, the patient's complete medical history and chart notes, and supporting clinical guidelines — each of these criteria is satisfied. The Facility respectfully submits that a thorough review of the enclosed documentation will confirm that the denied services meet the payer's own medical necessity standards and that the CO-50 denial should be overturned.

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III. ENCLOSED SUPPORTING DOCUMENTATION

In support of this appeal, the Facility encloses the following documents:

  1. Letter of Medical Necessity from the treating physician
  2. Clinical documentation supporting the diagnosis of E11.11 (Type 2 Diabetes Mellitus with Hypoglycemia)
  3. Operative report and/or procedure notes for CPT 43408 (Endoscopic Retrograde Cholangiopancreatography) and related procedures
  4. Peer-reviewed clinical guidelines on the endoscopic management of pancreatic and biliary conditions
  5. Prior authorization request and any prior communications with Synthetic Cigna regarding medical necessity for these services
  6. Patient's complete medical history and chart notes documenting the clinical indication for the procedures performed

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IV. REQUESTED REMEDY

Based on the foregoing, the Facility respectfully requests that Synthetic Cigna:

  1. Conduct a full and fair review of this appeal, including a review of all enclosed clinical documentation, by a qualified physician reviewer with appropriate expertise in gastroenterology or endoscopic procedures;
  2. Overturn the CO-50 medical necessity denial issued on March 1, 2026, with respect to Claim No. TEST-CLAIM-00069; and
  3. Reprocess Claim No. TEST-CLAIM-00069 and remit payment of the denied amount of $1,546.46 in accordance with the terms of the applicable coverage agreement.

Please note that the appeal deadline for this claim is June 29, 2026. The Facility requests a written determination within the timeframe prescribed by applicable state and federal regulations and the terms of the parties' agreement.

Should you require any additional information or documentation to complete your review, please contact the undersigned at the information provided below.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Email Address]
[Date]

Enclosures: As listed in Section III above