Appeal — TEST-CLAIM-00012

Date: [Date of Submission]

Synthetic Humana
Appeals and Grievances Department
[Payer Address]

RE: Formal Coding Appeal – Claim Denial Dispute
External Claim ID: TEST-CLAIM-00012
Internal Claim ID: ca1116f2-f490-4a01-a409-fd947da24215
Payer: Synthetic Humana
Service Date: April 16, 2026
Procedure Code(s): CPT 64040
Diagnosis Code(s): ICD-10 I10.94
Denial Date: June 21, 2026
Denied Amount: $2,918.34
Appeal Deadline: August 20, 2026

Dear Synthetic Humana Appeals Department,

On behalf of [Hospital/Facility Name], we are submitting this formal appeal in response to the denial issued on June 21, 2026, for the claim identified above (External Claim ID: TEST-CLAIM-00012). Synthetic Humana denied the above-referenced claim in the amount of $2,918.34, citing remark code CO-4: "The procedure code is inconsistent with the modifier used." We respectfully contest this determination and request that the claim be reprocessed and payment issued in full for the denied amount.

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I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The CO-4 denial asserts that the modifier appended to CPT 64040 (Supraorbital, infraorbital, or mental nerve block[s]) is incompatible with the procedure code as billed. We disagree with this determination. The clinical circumstances documented in the medical record substantiate the appropriateness of the modifier as applied, and the denial does not accurately reflect the services rendered on the date of service.

CPT 64040 describes nerve block procedures at distinct anatomic locations, including supraorbital, infraorbital, and mental nerve sites. Modifiers appended to nerve block procedures may be clinically warranted and coding-compliant when the documentation establishes qualifying circumstances such as bilateral performance, a distinct anatomic site, or other procedural specifics that align with nationally recognized coding guidelines. The clinical documentation for this claim supports precisely such circumstances, as further detailed in the enclosed supporting materials.

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II. SUPPORTING EVIDENCE

The following documentation is enclosed with this appeal and directly supports the appropriateness of the modifier as applied to CPT 64040:

1. Operative Report / Procedure Note – This document details the specific anatomic location(s) at which the nerve block procedure was performed on April 16, 2026, and substantiates the clinical basis for the modifier utilized. The operative report confirms the distinct procedural elements and anatomic parameters that justify the modifier in accordance with standard coding guidelines.

2. Clinical Documentation Supporting Medical Necessity – The enclosed clinical notes confirm the diagnosis of hypertension with chronic kidney disease (ICD-10 I10.94) and support the overall medical necessity of the procedure performed.

3. Modifier Justification Letter – The enclosed letter of modifier justification, prepared by [Facility's Coding and/or Clinical Team], provides a detailed explanation of the coding rationale, including the specific qualifying circumstance that necessitated the modifier appended to CPT 64040, and references applicable coding guidance.

4. Coding Review Memorandum – The enclosed coding review memo documents [Hospital/Facility Name]'s internal review of the claim, confirming that the modifier was appended in accordance with applicable coding guidelines and is consistent with the documented services.

Together, these documents demonstrate that the modifier applied to CPT 64040 is clinically appropriate, accurately reflects the services rendered, and is consistent with the procedure code under standard coding conventions.

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III. POLICY ANALYSIS

Synthetic Humana's denial is based on the payer's procedure code and modifier compatibility requirement. However, as set forth in applicable coding guidelines, a modifier is appropriately used with CPT 64040 when the clinical documentation establishes qualifying circumstances — including but not limited to bilateral performance or treatment at a distinct anatomic site — that differentiate the service from the base procedure description. The enclosed documentation substantiates such qualifying circumstances as present on the date of service.

A CO-4 denial based solely on a coding compatibility determination, without consideration of the underlying clinical documentation, does not adequately account for the clinical facts of this case. The denial is therefore subject to reversal upon review of the enclosed evidence, which clearly supports the modifier's appropriateness.

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IV. REQUESTED REMEDY

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

1. Conduct a full review of this appeal, including the enclosed supporting clinical and coding documentation;
2. Overturn the CO-4 denial issued on June 21, 2026, for claim TEST-CLAIM-00012;
3. Reprocess the claim with the modifier as originally submitted; and
4. Issue payment of the denied amount of $2,918.34 in accordance with the applicable contractual terms and timely payment obligations.

Should Synthetic Humana require any additional documentation or clarification, please contact [Hospital Contact Name] at [Contact Phone/Email]. We are committed to resolving this matter promptly and respectfully request a written determination prior to the appeal deadline of August 20, 2026.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Signature]
[Name and Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Date of Submission]

Enclosures:
- Operative Report / Procedure Note (Service Date: April 16, 2026)
- Clinical Documentation Supporting Medical Necessity
- Modifier Justification Letter
- Coding Review Memorandum
- Payer Coding Guidelines / Reference Material for CPT 64040 (as applicable)