Appeal — TEST-CLAIM-00030

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic Medicaid-TX
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00030
Internal Claim Reference: 436537e1-4afa-45dd-8158-b740283d389f
Payer: Synthetic Medicaid-TX
Date of Service: February 26, 2026
Denial Date: May 27, 2026
Denial Code: CO-55
Denied Amount: $2,230.61
Appeal Deadline: June 26, 2026

Dear Appeals and Grievances Department,

On behalf of our facility, we are submitting this formal first-level appeal in response to the denial of Claim TEST-CLAIM-00030, issued by Synthetic Medicaid-TX on May 27, 2026. The claim was denied under denial code CO-55, which classifies the billed procedures as experimental or investigational. We respectfully and strongly contest this determination. The procedures in question — CPT 58571 (hysteroscopy), CPT 19038 (breast biopsy), and CPT 76317 (ultrasound) — are well-established, FDA-cleared, and widely recognized as standard-of-care interventions within their respective clinical specialties. This denial is inconsistent with the published medical literature, applicable clinical guidelines, and the payer's own obligation to cover medically necessary, evidence-based care.

We respectfully request that Synthetic Medicaid-TX overturn this denial, reprocess Claim TEST-CLAIM-00030 in full, and remit payment of the denied amount of $2,230.61.

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I. BACKGROUND AND BASIS FOR DENIAL

On February 26, 2026, our facility rendered services to the patient covered under this claim, including procedures coded as CPT 58571 (hysteroscopy), CPT 19038 (breast biopsy), and CPT 76317 (ultrasound), in connection with diagnoses ICD-10 M17.53 (primary osteoarthritis, left knee) and R07.13 (chest pain on breathing). The total billed amount for the claim was $3,314.82, of which $2,230.61 was denied under CO-55 on the basis that the procedure or treatment is deemed experimental or investigational by the payer.

We assert that this classification is factually and clinically incorrect. The denial appears to misapply the payer's experimental/investigational exclusion policy to procedures that are unequivocally within the mainstream of established medical practice.

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II. GROUNDS FOR APPEAL

A. The Billed Procedures Are Not Experimental or Investigational

The designation of "experimental or investigational" under CO-55 is reserved for procedures that lack sufficient clinical evidence, peer-reviewed support, or regulatory approval to be considered accepted medical practice. CPT 58571, CPT 19038, and CPT 76317 do not meet this definition by any recognized standard.

— CPT 58571 (Hysteroscopy with ligation of fallopian tubes) is a well-established gynecological procedure with extensive clinical application, peer-reviewed literature support, and broad adoption within the specialty.

— CPT 19038 (Breast biopsy) represents a foundational diagnostic procedure in breast medicine, universally accepted and supported by decades of clinical evidence and professional society guidelines.

— CPT 76317 (Ultrasound) is among the most commonly performed diagnostic imaging studies in modern medicine and is a standard tool across multiple clinical disciplines.

All three procedures have received FDA clearance or approval, as applicable, and are recognized as medically necessary and appropriate by relevant specialty societies and clinical guideline bodies. The enclosed FDA clearance documentation and peer-reviewed clinical literature confirm this status.

B. Supporting Clinical Evidence Has Been Compiled

The following documents are enclosed with this appeal to substantiate the established, non-investigational nature of the billed procedures:

1. The enclosed letter of medical necessity from the treating physician, which details the clinical rationale for performing CPT 58571, 19038, and 76317 in the context of this patient's presenting diagnoses and clinical circumstances.

2. The enclosed peer-reviewed clinical guidelines and published literature demonstrating that the billed procedures are standard of care within their respective specialties and are not experimental or investigational.

3. The enclosed FDA clearance or approval documentation confirming the regulatory status of the billed procedures.

4. The enclosed published clinical studies and health outcomes data further establishing the accepted and routine nature of these procedures in clinical practice.

5. The enclosed standard-of-care documentation from the relevant specialty demonstrating the appropriateness of these procedures for patients presenting with diagnoses consistent with M17.53 and R07.13.

Collectively, these materials provide an unambiguous evidentiary basis for overturning the experimental/investigational classification.

C. The Payer's Experimental/Investigational Exclusion Policy Does Not Apply

Pursuant to Synthetic Medicaid-TX's experimental/investigational exclusion policy, procedures may be excluded only when they lack sufficient clinical evidence to support their safety, efficacy, and general acceptance within the medical community. As the enclosed documentation demonstrates, CPT 58571, 19038, and 76317 do not satisfy the criteria for such exclusion. They are, by any objective clinical measure, routine and accepted procedures. Application of the CO-55 denial code to these services is therefore inconsistent with the payer's own policy criteria and constitutes an erroneous denial.

We further note that the payer's medical policy document defining what constitutes "experimental" should be reviewed in light of the enclosed evidence. If the payer's internal medical policy has been applied in a manner that categorically excludes these procedures, we respectfully request that the applicable policy be provided as part of the appeal response, and that it be reconciled against the substantial clinical and regulatory evidence submitted herewith.

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III. REQUESTED REMEDY

Based on the foregoing, our facility respectfully requests the following:

1. Immediate reconsideration and overturn of the CO-55 denial applied to Claim TEST-CLAIM-00030.

2. Reprocessing of the claim in full, including all denied procedure codes (CPT 58571, 19038, and 76317) for the date of service of February 26, 2026.

3. Remittance of the denied amount of $2,230.61 in accordance with the applicable fee schedule and plan provisions.

If additional clinical information is required to complete the appeal review, please contact our Appeals Coordinator at the address or telephone number listed on this letterhead. We are committed to providing any supplemental documentation necessary to facilitate a prompt and fair resolution.

This appeal is being submitted within the applicable appeal deadline of June 26, 2026. We respectfully urge the payer to complete its review in a timely manner consistent with applicable regulatory timeframes.

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Thank you for your attention to this matter. We trust that upon review of the enclosed clinical evidence, payer policy analysis, and physician attestation, the payer will agree that the denial of Claim TEST-CLAIM-00030 under CO-55 was issued in error and that payment of the denied amount is warranted.

Respectfully submitted,

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

Enclosures:
- Letter of medical necessity from treating physician
- Peer-reviewed clinical guidelines and published literature (CPT 58571, 19038, 76317)
- FDA clearance/approval documentation
- Published clinical studies and health outcomes data
- Standard-of-care documentation for relevant specialty
- Copy of original claim (TEST-CLAIM-00030)
- Copy of Explanation of Benefits / denial notice dated May 27, 2026