Appeal — TEST-CLAIM-00025

Date: [Letter Date]

Via: [Submission Method]

Synthetic Cigna
Appeals & Grievances Department
[Payer Address]

Re:    Formal Appeal of Claim Denial
       Claim Number:       TEST-CLAIM-00025
       Payer:              Synthetic Cigna
       Date of Service:    February 28, 2026
       Denial Date:        May 2, 2026
       Denial Code:        CO-4
       Billed Amount:      $1,816.75
       Denied Amount:      $1,239.56
       Procedure Codes:    CPT 38906, 73993, 38760
       Diagnosis Codes:    ICD-10 S82.62, M17.49
       Appeal Deadline:    August 30, 2026

Dear Synthetic Cigna Appeals Department,

On behalf of the treating facility, we hereby submit this formal first-level appeal contesting Synthetic Cigna's denial of Claim TEST-CLAIM-00025, issued on May 2, 2026, for services rendered on February 28, 2026. The claim was denied under denial code CO-4, asserting that the procedure code(s) are inconsistent with the modifier(s) used. For the reasons set forth below, and as supported by the enclosed clinical and coding documentation, we respectfully request that this denial be overturned and that the claim be reprocessed for full payment of the denied amount of $1,239.56.

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I. BACKGROUND AND BASIS FOR DENIAL

Synthetic Cigna issued a CO-4 denial, which indicates that the modifier(s) applied to the billed procedure codes are considered inconsistent with those procedure codes as submitted. The procedures at issue are CPT 38906 (lymph node biopsy), CPT 73993 (ankle/foot imaging), and CPT 38760 (inguinal lymphadenectomy), all performed on February 28, 2026, in connection with the patient's documented diagnoses.

We respectfully disagree with this determination. The clinical record, operative documentation, and authoritative CPT coding references collectively demonstrate that the modifier(s) applied to these procedure codes are both clinically appropriate and coding-technically correct, accurately reflecting the distinct services performed on the date of service.

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II. GROUNDS FOR APPEAL

A. The Operative Record Supports the Modifier Application

The enclosed operative report provides a detailed, contemporaneous description of each procedure performed on February 28, 2026. This report confirms that the procedures billed under CPT 38906, CPT 73993, and CPT 38760 were each separately and distinctly performed, and that the modifier(s) in question were applied to accurately reflect the clinical circumstances of those services — including, as applicable, the distinct nature, anatomical site, or sequence of the procedures. The operative report directly contradicts any assertion that the modifier usage does not align with the procedures as performed.

B. The Surgeon's Modifier Justification Letter Explains the Clinical and Coding Rationale

The enclosed modifier justification letter from the treating surgeon provides a clear, procedure-specific explanation of why the modifier(s) were applied to the relevant CPT code(s). The surgeon's attestation confirms that the modifier selection accurately represents the nature of the services rendered and is consistent with both the clinical facts and applicable coding standards. This letter directly addresses the CO-4 denial rationale and should be given significant weight in the payer's review.

C. CPT Coding Guidelines and Peer-Reviewed References Confirm Modifier Compatibility

The enclosed CPT coding reference guidelines, specific to procedures 38906, 73993, and 38760, demonstrate that the modifier-code combination at issue does not violate bundling rules, modifier compatibility requirements, or any other applicable coding standard. Additionally, the enclosed peer-reviewed clinical guidelines further substantiate that the modifier application is appropriate for the bundled procedures as billed. There is no basis under authoritative CPT guidance to conclude that the modifier(s) are incompatible with the procedure codes submitted.

D. Corroborating Clinical Documentation Is Consistent with the Billed Coding

The enclosed anesthesia record, imaging reports corresponding to CPT 73993, and pathology report related to CPT 38906 provide additional corroboration that the procedures were performed as documented and billed. Taken together, this body of documentation establishes a complete and consistent clinical record supporting the accuracy of the coding, including the modifier(s) at issue.

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III. APPLICABLE PAYER POLICY

We acknowledge that Synthetic Cigna's billing policies require compatibility between procedure codes and any modifiers applied. We assert that the documentation provided herein — specifically the operative report, the surgeon's modifier justification letter, and the CPT coding references — conclusively demonstrates that this requirement is satisfied. The modifier(s) applied to CPT 38906, CPT 73993, and CPT 38760 accurately reflect the distinct services rendered on February 28, 2026, and do not violate Synthetic Cigna's procedure code and modifier compatibility requirements.

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IV. REQUESTED REMEDY

In light of the foregoing, we respectfully request that Synthetic Cigna:

1. Conduct a thorough review of the enclosed clinical and coding documentation in connection with Claim TEST-CLAIM-00025;
2. Overturn the CO-4 denial in its entirety;
3. Reprocess Claim TEST-CLAIM-00025 in accordance with the patient's applicable benefits; and
4. Issue payment of the full denied amount of $1,239.56.

This appeal is being submitted in advance of the appeal deadline of August 30, 2026. We respectfully request written confirmation of receipt and a determination within the timeframes required by applicable regulations and Synthetic Cigna's own appeals policies.

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V. ENCLOSED DOCUMENTATION

The following documents are enclosed in support of this appeal:

  1. Operative report with detailed procedure description (February 28, 2026)
  2. Anesthesia record
  3. Pathology report (related to CPT 38906)
  4. Imaging reports (related to CPT 73993)
  5. Modifier justification letter from the treating surgeon
  6. CPT coding reference guidelines for procedures 38906, 73993, and 38760
  7. Peer-reviewed clinical guidelines supporting the procedure-modifier combination

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We appreciate Synthetic Cigna's prompt and thorough attention to this matter. If additional information or clarification is needed, please do not hesitate to contact our Appeals Department at the information below.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures: As listed above