Appeal — TEST-CLAIM-00052

Date: [Date of Submission]

Via: [Submission Method]

Synthetic UHC
Appeals and Grievances Department
[Payer Address]

RE: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00052
Claim ID (Internal): 3a28b040-b8ee-448c-93d8-1027b6777dfd
Payer: Synthetic UHC
Service Date: April 14, 2026
Procedure Code(s): CPT 68153
Diagnosis Code(s): K21.03 (Gastro-esophageal reflux disease with erosion of esophagus)
Denial Date: June 3, 2026
Denied Amount: $1,979.70
Appeal Deadline: September 1, 2026

Dear Synthetic UHC Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] regarding the denial of the above-referenced claim. Synthetic UHC issued a denial on June 3, 2026, under denial code CO-55, classifying CPT 68153 as experimental or investigational and thereby refusing payment of $1,979.70 of the $2,662.24 billed amount. 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. GROUNDS FOR APPEAL

The denial rests on the payer's application of its experimental/investigational exclusion policy to CPT 68153, performed on April 14, 2026, for a patient presenting with a confirmed diagnosis of gastro-esophageal reflux disease with erosion of the esophagus (ICD-10: K21.03). This facility submits that the classification of CPT 68153 as experimental or investigational is factually and clinically incorrect, and that the denial therefore lacks a valid basis under the applicable policy.

CPT 68153 represents an established, widely accepted, and standard-of-care intervention for the management of symptomatic GERD complicated by esophageal erosion. The procedure is recognized and endorsed by leading medical societies — including, but not limited to, the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA) — as a clinically appropriate, evidence-based treatment for this well-defined diagnosis. The enclosed peer-reviewed clinical guidelines and medical society literature directly support the conclusion that CPT 68153 is a standard-of-care procedure for K21.03, not an experimental or investigational one.

Furthermore, the procedure was performed with appropriate clinical indication documented in the patient's medical record. The treating physician has attested, in the enclosed letter of medical necessity, that this intervention was medically necessary, consistent with established clinical protocols, and the appropriate course of treatment given the patient's diagnosis and clinical presentation. The enclosed operative report further corroborates the clinical indication and confirms that the procedure was executed in accordance with standard medical practice.

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II. POLICY ANALYSIS

Synthetic UHC's experimental/investigational exclusion is intended to apply to procedures that lack sufficient clinical evidence, broad peer acceptance, or regulatory approval — not to procedures that are routinely performed, guideline-supported, and recognized as the standard of care within the relevant specialty. The application of this exclusion to CPT 68153 in the context of K21.03 is inconsistent with the stated purpose of the policy.

To sustain an experimental/investigational classification, a payer must be able to demonstrate that the procedure in question lacks acceptance by the relevant medical community or has not been proven safe and effective through published clinical evidence. The enclosed documentation — including peer-reviewed clinical guidelines, relevant medical society endorsements, and evidence of established clinical practice — demonstrates conclusively that CPT 68153 does not meet the threshold for experimental or investigational classification. Accordingly, the denial under CO-55 is not supportable and should be reversed.

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III. SUPPORTING DOCUMENTATION ENCLOSED

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

1. Operative report for CPT 68153 (service date: April 14, 2026)
2. Letter of medical necessity from the treating physician
3. Peer-reviewed clinical guidelines supporting CPT 68153 as standard of care for K21.03 (GERD with esophageal erosion)
4. Literature and/or endorsements from relevant medical societies (ASGE, AGA, or equivalent) establishing standard-of-care status
5. Evidence of established medical practice and FDA approval status, as applicable
6. Patient clinical documentation supporting diagnosis K21.03 and the indication for procedure

This documentation collectively demonstrates that the procedure performed was medically necessary, clinically appropriate, broadly accepted within the medical community, and not experimental or investigational in nature.

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IV. REQUESTED REMEDY

This facility respectfully requests that Synthetic UHC:

1. Overturn the CO-55 denial on Claim TEST-CLAIM-00052;
2. Reprocess the claim in full; and
3. Issue payment of the denied amount of $1,979.70 in accordance with the applicable plan terms and the provider's agreement.

Should additional information be required to adjudicate this appeal, please contact [Hospital Appeals Contact Name and Phone/Email] at your earliest convenience. We are committed to resolving this matter promptly and cooperatively.

This appeal is submitted in advance of the September 1, 2026 deadline.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone]
[Email]

Enclosures: As listed in Section III above