Appeal — TEST-CLAIM-00039

Date: [Date of Submission]

Via: [Submission Method]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

Re:     Formal Appeal of Medical Necessity Denial
        Claim Number:       TEST-CLAIM-00039
        Payer:              Synthetic Humana
        Service Date:       May 22, 2026
        Procedure Code:     CPT 91987 (Esophageal Reflux Monitoring)
        Diagnosis Code:     ICD-10 K21.84 (Gastroesophageal Reflux Disease)
        Billed Amount:      $5,717.30
        Denied Amount:      $5,507.55
        Denial Date:        June 12, 2026
        Appeal Deadline:    August 11, 2026

Dear Appeals and Grievances Review Committee:

On behalf of [Facility Name], we are submitting this formal first-level appeal contesting the denial issued on June 12, 2026, for Claim No. TEST-CLAIM-00039. Synthetic Humana denied payment in the amount of $5,507.55 under adjustment reason code CO-50, asserting that the esophageal reflux monitoring service (CPT 91987) performed on May 22, 2026, was not medically necessary. For the reasons set forth below, and in light of the clinical documentation and applicable guidelines enclosed herewith, we respectfully request that this denial be overturned and that the claim be reprocessed for full payment of the denied amount.

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I. BACKGROUND AND NATURE OF THE DENIAL

On May 22, 2026, the treating physician performed esophageal reflux monitoring (CPT 91987) for a patient with a documented diagnosis of gastroesophageal reflux disease (ICD-10 K21.84). A claim was submitted to Synthetic Humana in the total billed amount of $5,717.30. On June 12, 2026, Synthetic Humana issued a denial of $5,507.55 citing CO-50 — medical necessity not established.

We respectfully disagree with this determination. The service was performed in direct response to a documented clinical indication, was ordered by the patient's treating physician, and is supported by peer-reviewed clinical guidelines as an appropriate diagnostic procedure for the patient's confirmed condition.

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II. BASIS FOR APPEAL

A. The Treating Physician Has Documented Medical Necessity

The patient carries a confirmed diagnosis of gastroesophageal reflux disease (K21.84). The treating physician determined that esophageal reflux monitoring (CPT 91987) was clinically indicated based on the patient's presentation, symptom history, and prior diagnostic workup. The enclosed physician's letter of medical necessity details the specific clinical rationale that prompted the ordering of this procedure, including the patient's documented symptoms, prior treatment course, and the diagnostic questions that the monitoring was intended to answer. Synthetic Humana's denial does not appear to have adequately weighed or accounted for this individualized clinical judgment.

B. Clinical Documentation from the Service Date Supports the Indication

The enclosed clinical documentation from May 22, 2026 — including progress notes and the clinical evaluation — corroborates the physician's determination that esophageal pH monitoring was necessary at that time. This documentation demonstrates that the procedure was not elective or duplicative, but was a diagnostically appropriate step in the management of the patient's confirmed GERD diagnosis.

C. Peer-Reviewed Clinical Guidelines Establish CPT 91987 as Appropriate for ICD-10 K21.84

Established clinical guidelines from relevant professional societies support the use of esophageal reflux monitoring in the evaluation and management of gastroesophageal reflux disease. The enclosed peer-reviewed clinical guidelines confirm that CPT 91987 is a recognized, evidence-based diagnostic tool for patients presenting with the documented condition (K21.84). The payer's blanket application of CO-50 without apparent reference to these guidelines is inconsistent with the standard of care and the applicable medical necessity criteria.

D. The Denial Is Inconsistent with the Payer's Own Medical Necessity Criteria

Synthetic Humana's medical necessity criteria provide the framework against which covered services are evaluated. The combination of a confirmed GERD diagnosis (K21.84), the treating physician's documented clinical rationale, corroborating diagnostic findings, and guideline-based support for CPT 91987 satisfies the elements of medical necessity as generally defined under the payer's own policy standard. We respectfully submit that a thorough review of the enclosed documentation will demonstrate that this claim meets the applicable criteria for coverage.

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III. SUPPORTING DOCUMENTATION ENCLOSED

The following documents are enclosed in support of this appeal:

1. Physician's Letter of Medical Necessity — detailing the treating physician's clinical rationale for ordering CPT 91987 on May 22, 2026.
2. Clinical Documentation from the Service Date — including progress notes and clinical evaluation reflecting the patient's presentation and the basis for the procedure.
3. Peer-Reviewed Clinical Guidelines — supporting the use of esophageal reflux monitoring (CPT 91987) for patients with a diagnosis of K21.84.
4. Relevant Diagnostic Test Results or Imaging — establishing the clinical indication and prior workup that informed the treating physician's decision.
5. Prior Authorization Request and Any Related Insurer Correspondence — provided for reference regarding the medical necessity criteria at issue.

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IV. REQUESTED REMEDY

Based on the foregoing, [Facility Name] respectfully requests that Synthetic Humana:

1. Overturn the CO-50 medical necessity denial issued on June 12, 2026, for Claim No. TEST-CLAIM-00039;
2. Reprocess the claim for CPT 91987 with service date May 22, 2026; and
3. Issue payment of the denied amount of $5,507.55 in accordance with the patient's applicable benefit plan.

Should the reviewing medical director or appeals examiner require any additional clinical information or clarification, please contact [Provider Contact Name] at [Phone Number] or [Email Address]. We are committed to providing any further documentation necessary to support a favorable resolution.

We appreciate Synthetic Humana's timely consideration of this appeal and trust that a thorough review of the enclosed clinical record will support a reversal of the denial.

Respectfully submitted,

[Authorized Signature]
[Printed Name and Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Date]