Appeal — TEST-CLAIM-00011

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Cigna
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Reference Number: TEST-CLAIM-00011
Payer: Synthetic Cigna
Date of Service: March 15, 2026
Procedure Code(s): CPT 56898
Diagnosis Code(s): J45.85 (Asthma with obstruction)
Denial Date: June 7, 2026
Denied Amount: $824.88
Appeal Deadline: October 5, 2026

Dear Appeals and Grievances Department,

On behalf of our facility, we are submitting this formal appeal to contest the denial of Claim TEST-CLAIM-00011, issued by Synthetic Cigna on June 7, 2026. The claim was denied under adjustment reason code CO-55, whereby Synthetic Cigna classified CPT 56898 as an experimental or investigational procedure for the treatment of diagnosis J45.85 (asthma with obstruction), performed on March 15, 2026. We respectfully disagree with this determination and request that Synthetic Cigna overturn the denial and reprocess the claim for payment of the denied amount of $824.88.

I. GROUNDS FOR APPEAL

The denial of this claim under CO-55 is not supported by the current body of clinical evidence, peer-reviewed literature, or established treatment guidelines applicable to CPT 56898 for the treatment of J45.85. The application of the experimental/investigational exclusion in this instance is inconsistent with the medical evidence and with the standard criteria payers are required to evaluate before applying such an exclusion.

Before classifying a procedure as experimental or investigational, Synthetic Cigna's own policy framework requires an objective assessment of clinical acceptance and demonstrated efficacy. As the enclosed supporting documentation establishes, CPT 56898 meets the threshold for accepted, standard-of-care treatment for asthma with obstruction (J45.85) and should not be subject to exclusion under the experimental/investigational provision.

II. SUPPORTING EVIDENCE

In support of this appeal, we are enclosing the following documentation:

1. Letter of Medical Necessity — The enclosed letter of medical necessity from the treating physician documents the clinical rationale for performing CPT 56898 for this specific patient and diagnosis (J45.85), affirming that the procedure was medically indicated and consistent with accepted treatment protocols.

2. Peer-Reviewed Clinical Guidelines — The enclosed peer-reviewed clinical guidelines and/or applicable FDA guidance directly address the clinical acceptance of CPT 56898, demonstrating that this procedure is recognized within the medical community as an established and effective treatment modality.

3. Published Clinical Literature — The enclosed published literature and clinical studies provide further evidence that CPT 56898 has demonstrated clinical efficacy and is considered standard of care for patients presenting with J45.85. This body of evidence directly refutes the characterization of the procedure as experimental or investigational.

4. Operative Report and Procedure Documentation — The enclosed operative report confirms that CPT 56898 was performed on March 15, 2026, in accordance with accepted clinical protocols and in direct response to the patient's documented diagnosis of asthma with obstruction.

Taken together, these materials demonstrate that the experimental/investigational exclusion under CO-55 is inapplicable to this claim and that the procedure meets the standard criteria for covered, medically necessary care.

III. POLICY ANALYSIS

Synthetic Cigna's experimental/investigational exclusion policy requires that before a procedure is classified as experimental or investigational, the payer must evaluate whether the procedure has achieved clinical acceptance and demonstrated efficacy within the relevant medical community. The enclosed clinical guidelines, peer-reviewed literature, and physician documentation collectively establish that CPT 56898 satisfies these criteria for the treatment of J45.85. The denial therefore misapplies the exclusion and is inconsistent with the evidence available at the time of service and at the time of this appeal.

IV. REQUESTED REMEDY

We respectfully request that Synthetic Cigna:

1. Overturn the CO-55 denial for Claim TEST-CLAIM-00011;
2. Reprocess the claim in accordance with the applicable contractual and coverage terms; and
3. Issue payment for the denied amount of $824.88.

We believe the enclosed documentation is sufficient to resolve this matter at the first level of appeal; however, our facility reserves the right to pursue all further levels of appeal, including external independent review, should this appeal not be resolved in our favor.

Please confirm receipt of this appeal and provide a written determination within the timeframe required by applicable regulations and the terms of our provider agreement. If additional information is needed to process this appeal, please do not hesitate to contact our Provider Relations or Appeals department at the address or telephone number below.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Signatory Name and Title]
[Facility Name]
[Facility Address]
[Telephone Number]
[Fax Number]
[Provider NPI]

Enclosures:
- Letter of Medical Necessity (Treating Physician)
- Peer-Reviewed Clinical Guidelines / FDA Guidance on CPT 56898
- Published Clinical Literature Supporting Standard-of-Care Status
- Operative Report / Procedure Documentation