Appeal — TEST-CLAIM-00041

Date: [Date of Submission]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00041
Internal Claim ID: ea753f56-6b57-4f77-8c56-296cd0d66d12
Date of Service: February 20, 2026
Denial Date: April 3, 2026
Procedure Code(s): CPT 17816
Diagnosis Code(s): ICD-10 K21.76
Denied Amount: $31,552.50
Appeal Deadline: September 30, 2026

Dear Synthetic Aetna Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the denial of Claim TEST-CLAIM-00041, issued on April 3, 2026. The claim was denied under reason code CO-55, which classifies CPT 17816 (cryotherapy) as experimental or investigational. We respectfully contest this determination and request that the claim be reprocessed and payment of the denied amount of $31,552.50 be issued in full.

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I. BACKGROUND AND BASIS FOR DENIAL

On February 20, 2026, our facility performed cryotherapy (CPT 17816) on a patient presenting with a documented diagnosis of gastroesophageal reflux disease with esophageal stricture (ICD-10 K21.76). Following adjudication, Synthetic Aetna denied $31,552.50 of the $35,910.54 billed amount, citing CO-55 — that the procedure is deemed experimental or investigational by the payer.

We respectfully submit that this denial is not consistent with the current body of clinical evidence, applicable professional society guidelines, and established standards of care governing the use of cryotherapy for esophageal conditions.

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II. GROUNDS FOR APPEAL

A. Cryotherapy (CPT 17816) Is a Recognized, Evidence-Based Standard of Care for the Documented Diagnosis

The payer's application of the experimental/investigational exclusion to CPT 17816 in the context of diagnosis K21.76 is not supported by the weight of current medical evidence. Cryotherapy for esophageal conditions, including management of stricture associated with gastroesophageal reflux disease, has achieved broad clinical acceptance within the gastroenterological and medical community. As documented in the enclosed peer-reviewed clinical literature and journal articles, this procedure is widely performed, studied, and endorsed as a standard therapeutic option — not a novel or unproven intervention.

For a procedure to meet the threshold criteria typically applied by payers in classifying a treatment as experimental or investigational, it must generally lack sufficient clinical evidence of safety and efficacy, be limited to research protocols, or have failed to gain acceptance among relevant medical professional communities. CPT 17816, as applied to the patient's diagnosed condition, meets none of these criteria.

B. Professional Society Guidelines and FDA Documentation Support the Procedure

The enclosed clinical practice guidelines from recognized professional medical societies affirm that cryotherapy is an accepted treatment modality for patients with esophageal conditions consistent with this patient's diagnosis. Additionally, any applicable FDA clearance or approval documentation enclosed herewith further supports that this procedure has met the regulatory standards for safety and effectiveness required for clinical use in the United States.

C. Medical Necessity Was Thoroughly Documented

The enclosed letter of medical necessity from the treating physician details the clinical indications that prompted the use of CPT 17816, the severity of the patient's condition as documented in the enclosed medical records, and the clinical rationale supporting this course of treatment — including, where applicable, prior conservative treatments that were attempted or considered. This documentation demonstrates that the procedure was not performed experimentally but was selected as an appropriate, medically necessary intervention based on the patient's specific clinical presentation.

D. The Payer's Experimental/Investigational Exclusion Policy Is Not Properly Applicable

Per Synthetic Aetna's own experimental/investigational exclusion policy, determinations under this category must be grounded in a finding that the procedure lacks sufficient clinical validation or professional acceptance. The enclosed supporting documentation — including peer-reviewed literature, clinical guidelines, and the physician's letter of medical necessity — directly and materially undermines each basis upon which such a classification could rest. Accordingly, the CO-55 denial code has been misapplied to this claim, and the denial should be reversed.

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III. SUPPORTING DOCUMENTATION ENCLOSED

In support of this appeal, the following documents are enclosed for the reviewer's consideration:

1. Letter of medical necessity from the treating physician, documenting clinical indications and rationale for CPT 17816
2. Patient medical records documenting the severity of the diagnosed condition (ICD-10 K21.76) and relevant clinical history
3. Peer-reviewed clinical literature and journal articles establishing cryotherapy as a recognized standard of care for esophageal conditions
4. Clinical practice guidelines from applicable professional medical societies supporting the use of CPT 17816 for this indication
5. FDA approval or clearance documentation applicable to the procedure, if available
6. Prior authorization or payer coverage policy documentation, where applicable, demonstrating coverage of comparable procedures

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IV. REQUESTED REMEDY

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

1. Overturn the CO-55 denial determination as it applies to Claim TEST-CLAIM-00041;
2. Reprocess the claim in full under the patient's applicable benefit plan; and
3. Issue payment of the denied amount of $31,552.50 in accordance with the contracted rate and plan terms.

This appeal is being submitted within the applicable appeal deadline of September 30, 2026. We request written confirmation of receipt and a determination within the timeframe required under applicable state and federal regulations and Synthetic Aetna's own appeals process.

Should the reviewing clinician or appeals specialist require any additional clinical information or documentation to complete the review, we welcome the opportunity to supplement this record and request that we be contacted promptly so that we may provide any such information without delay.

Thank you for your prompt and thorough consideration of this appeal. We trust that a review of the enclosed documentation will confirm that CPT 17816 was performed as a medically necessary, clinically accepted procedure and that the CO-55 denial should be overturned.

Respectfully submitted,

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

Enclosures: As listed in Section III above