Appeal — TEST-CLAIM-00093

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic UHC

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00093
Payer: Synthetic UHC
Service Date: March 9, 2026
Denial Date: May 29, 2026
Denied Amount: $818.75
Procedure Code(s): CPT 16258
Diagnosis Code(s): ICD-10 S82.81
Appeal Deadline: August 27, 2026

Dear Appeals and Grievances Department,

On behalf of the undersigned facility, we are formally appealing the denial issued on May 29, 2026, for Claim Number TEST-CLAIM-00093. Synthetic UHC denied $818.75 of the total billed amount under denial code CO-197, citing the absence of precertification, authorization, or notification for CPT 16258 (rendered on March 9, 2026, for the treatment of ICD-10 S82.81, fracture of the fibula). We respectfully contend that this denial is not supported by the facts and request that the claim be reprocessed and the denied amount of $818.75 be paid in full.

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BASIS FOR APPEAL

I. Prior Authorization Was Obtained Prior to or at the Time of Service

Contrary to the assertion in the CO-197 denial, prior authorization for CPT 16258 was secured in accordance with Synthetic UHC's precertification requirements. The enclosed prior authorization approval letter from Synthetic UHC confirms that authorization was granted. Additionally, the enclosed precertification request documentation with timestamps demonstrates that the authorization request was submitted in a timely manner relative to the service date of March 9, 2026. Proof of timely submission — including fax logs, tracking records, or payer portal confirmation — is also enclosed and establishes that the facility fulfilled its precertification obligations.

II. Payer Records Should Reflect the Granted Authorization

Because authorization was obtained through Synthetic UHC's own precertification process, the payer's internal records and systems should independently corroborate the approval. The enclosed correspondence reflecting the payer's receipt acknowledgment or system records further substantiates that Synthetic UHC was properly notified and that authorization was on file at the time of service. The denial under CO-197, therefore, appears to have been issued in error — possibly due to an administrative oversight in linking the authorization to this claim — and does not reflect the actual status of the precertification.

III. Medical Necessity for CPT 16258 Is Well-Supported

Should there be any question regarding the clinical appropriateness of the services rendered, the enclosed letter of medical necessity documents the clinical rationale supporting the use of CPT 16258 for the treatment of ICD-10 S82.81 (fracture of the fibula). The service was medically necessary and appropriate for the patient's diagnosed condition, consistent with evidence-based clinical standards.

IV. The Denial Is Disputable Under Synthetic UHC's Own Prior Authorization Policy

Synthetic UHC's prior authorization requirements provide that when precertification has been obtained and confirmed, claims associated with the authorized service should be processed and paid accordingly. Because the evidence establishes that authorization was properly obtained, the basis for the CO-197 denial — that precertification was absent — is factually inaccurate. Sustaining this denial in the face of documented authorization approval would be inconsistent with Synthetic UHC's own policy framework and contrary to the submitted evidence.

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ENCLOSED DOCUMENTATION

In support of this appeal, the following documents are enclosed for review:

1. Prior authorization approval letter from Synthetic UHC
2. Precertification request documentation with timestamps
3. Proof of timely submission (fax log, tracking records, or payer portal confirmation)
4. Letter of medical necessity supporting CPT 16258 for ICD-10 S82.81
5. Correspondence reflecting payer's receipt acknowledgment or system records

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REQUESTED REMEDY

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

1. Overturn the denial issued under CO-197 for Claim Number TEST-CLAIM-00093;
2. Reprocess the claim in its entirety; and
3. Issue payment of the denied amount of $818.75 in accordance with the applicable plan terms and the authorization previously granted.

Please note that the deadline for this appeal is August 27, 2026. We ask that this matter be reviewed and resolved prior to that date. Should additional information be required, please contact our billing and appeals department at your earliest convenience.

Thank you for your prompt attention to this matter. We trust that a thorough review of the enclosed documentation will confirm that the denial was issued in error and that payment is warranted.

Respectfully submitted,

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