Appeal — TEST-CLAIM-00060

Date: [Date of Submission]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Medical Necessity Denial
Claim Number: TEST-CLAIM-00060
Service Date: April 16, 2026
Denial Date: May 8, 2026
Procedure Codes: 63516, 25292, 28320
Diagnosis Code(s): M17.38
Denied Amount: $3,482.35
Appeal Deadline: July 7, 2026

Dear Synthetic Humana Appeals Department,

On behalf of the undersigned facility, we are submitting this formal written appeal contesting the denial issued on May 8, 2026, for Claim Number TEST-CLAIM-00060. Synthetic Humana denied the above-referenced claim under adjustment reason code CO-50, asserting that the spinal decompression (CPT 63516), wrist arthroscopy/surgical repair (CPT 25292), and foot surgery (CPT 28320) performed on April 16, 2026, did not meet the payer's medical necessity criteria. We respectfully disagree with this determination and request that the denial be overturned and the claim reprocessed for payment of the full denied amount of $3,482.35.

I. GROUNDS FOR APPEAL

The denial under CO-50 is not supported by the totality of the clinical record. The procedures billed were performed at anatomically distinct sites — the spine, wrist, and foot — each representing a separately documented and clinically indicated surgical intervention. The medical record, as detailed in the enclosed supporting documentation, clearly establishes that these procedures were medically necessary, evidence-based, and consistent with accepted standards of care for the patient's documented diagnoses and symptom burden.

Specifically, the enclosed documentation demonstrates the following:

• Conservative Treatment Failure: The enclosed evidence of conservative treatment attempts prior to surgery establishes that non-surgical management was pursued and exhausted prior to the decision to proceed with operative intervention. Surgery was not undertaken as a first-line option, but rather as a clinically necessary step following the failure of appropriate conservative measures.

• Physician Attestation of Medical Necessity: The enclosed letter of medical necessity from the treating physician articulates the clinical rationale for each of the three procedures, the severity of the patient's symptoms, and the basis upon which surgical intervention was deemed necessary. This professional judgment should be afforded appropriate weight in the payer's reconsideration.

• Operative Documentation: The enclosed operative reports for CPT codes 63516, 25292, and 28320 provide contemporaneous, procedure-specific documentation of the surgical findings and interventions performed on April 16, 2026, confirming that the billed procedures were actually and appropriately performed.

• Diagnostic Imaging and Clinical Evidence: The enclosed imaging studies and diagnostic test results objectively corroborate the severity of the structural pathology underlying each surgical site, further substantiating the clinical indication for operative management.

• Alignment with Clinical Guidelines: The enclosed peer-reviewed clinical guidelines support surgical intervention for the documented conditions and symptom severity. The procedures performed are consistent with nationally recognized standards of care.

• Comprehensive Medical History: The enclosed patient medical history and comorbidity documentation provides additional clinical context that is integral to a complete medical necessity determination. We respectfully note that the primary diagnosis code submitted (M17.38) may not fully capture all of the conditions addressed across the three distinct anatomical sites treated on the date of service. The clinical documentation enclosed reflects the full scope of the patient's diagnoses and the corresponding necessity for each procedure. We request that the payer review the complete clinical record rather than limiting its necessity determination to the primary diagnosis code alone.

II. POLICY BASIS FOR APPEAL

Synthetic Humana's medical necessity criteria require that covered services be clinically appropriate and supported by documented evidence of need. The clinical record submitted herewith — comprising the physician letter of medical necessity, operative reports, imaging studies, evidence of conservative treatment failure, peer-reviewed guidelines, and the patient's comprehensive medical history — collectively satisfies those criteria. The payer's CO-50 denial appears to have been issued without full consideration of the available clinical evidence. A denial of medical necessity that does not account for the complete clinical record is inconsistent with the payer's own policy obligations and applicable coverage standards.

III. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic Humana:

1. Conduct a thorough review of this appeal and all enclosed supporting documentation;
2. Overturn the May 8, 2026 medical necessity denial for Claim Number TEST-CLAIM-00060; and
3. Reprocess the claim and issue payment of the full denied amount of $3,482.35 in accordance with the applicable contractual terms and benefit provisions.

Should Synthetic Humana require any additional clinical documentation or a peer-to-peer review with the treating physician, please do not hesitate to contact our office at the information provided below. We are committed to working collaboratively to resolve this matter promptly and respectfully request a response in advance of the appeal deadline of July 7, 2026.

Thank you for your prompt attention to this appeal.

Respectfully submitted,

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

Enclosures:
- Letter of medical necessity from treating physician
- Operative reports for CPT 63516, 25292, and 28320
- Clinical documentation supporting diagnosis and symptom severity
- Evidence of conservative treatment attempts prior to surgery
- Imaging studies and diagnostic test results
- Peer-reviewed clinical guidelines supporting surgical intervention
- Patient medical history and comorbidities