Appeal — TEST-CLAIM-00070

Date: [Date of Letter]

Appeal and Grievance Unit
Synthetic Medicaid-TX
[Payer Address]
[City, State, ZIP]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00070
Payer: Synthetic Medicaid-TX
Service Date: 2026-04-28
Denial Date: 2026-05-28
Denied Amount: $2,550.13
Procedure Codes: CPT 97819, CPT 26021
Diagnosis Codes: ICD-10 N39.85, ICD-10 S82.92

Dear Appeals and Grievance Review Committee:

On behalf of the treating facility, we are submitting this formal appeal of the denial issued on 2026-05-28 for claim TEST-CLAIM-00070, submitted to Synthetic Medicaid-TX for services rendered on 2026-04-28. The claim, totaling $3,679.26 in billed charges, was denied in the amount of $2,550.13 under reason code CO-55, with the payer classifying CPT 97819 (physical therapy procedure) and CPT 26021 (surgical procedure on the hand) as experimental or investigational in nature. We respectfully but firmly contest this determination and request that the claim be reprocessed and paid in full.

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GROUNDS FOR APPEAL

I. The Procedures at Issue Are Established, Widely Accepted Standards of Care

The payer's application of its experimental/investigational exclusion to CPT 97819 and CPT 26021 is not supported by the current body of clinical evidence. Both procedure codes represent recognized, evidence-based interventions that are broadly accepted within the medical community and are routinely performed in the treatment of diagnoses consistent with those documented on this claim — ICD-10 N39.85 and ICD-10 S82.92. A determination of experimental or investigational status is appropriate only where a procedure lacks sufficient clinical evidence of safety, efficacy, and general acceptance among qualified health professionals. That threshold cannot be met here.

As detailed in the enclosed peer-reviewed clinical guidelines and supporting clinical literature, CPT 97819 and CPT 26021 are firmly established within the standard of care for the patient's documented conditions. These procedures are neither novel nor lacking in evidence; they are supported by published, peer-reviewed research and recognized clinical practice standards. We respectfully request that the payer's reviewing clinician give full and objective consideration to this body of evidence.

II. The Treating Physician Has Documented Medical Necessity

The enclosed letter of medical necessity from the treating physician sets forth in detail the clinical basis for selecting CPT 97819 and CPT 26021 to address the patient's diagnoses of ICD-10 N39.85 and ICD-10 S82.92. The treating physician, who has direct knowledge of the patient's condition, clinical history, and response to care, attests that these procedures were medically indicated, clinically appropriate, and consistent with accepted professional standards. The enclosed treatment plan and clinical notes further corroborate the medical necessity of the services rendered on 2026-04-28.

Where applicable, the enclosed documentation also reflects prior conservative treatment attempts and the clinical rationale for proceeding with the billed procedures, further demonstrating that the plan of care followed an appropriate, evidence-based progression.

III. The Payer's Own Coverage Criteria Support Approval

The enclosed copy of the payer's applicable clinical policy and coverage determination criteria for CPT 97819 and CPT 26021 demonstrates that the conditions for coverage are met in this case. To the extent that Synthetic Medicaid-TX has established criteria by which a procedure may be deemed non-experimental, the clinical facts of this claim satisfy those criteria. The denial therefore appears to rest on an incorrect or incomplete application of the plan's own policy standards, and reversal on reconsideration is warranted.

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SUMMARY AND REQUESTED REMEDY

The denial of claim TEST-CLAIM-00070 under CO-55 is not supported by the clinical evidence, applicable peer-reviewed guidelines, or the payer's own coverage determination criteria. CPT 97819 and CPT 26021 are standard-of-care procedures for the documented diagnoses, and the treating physician has clearly established their medical necessity. Accordingly, we respectfully request the following:

1. Immediate reconsideration and overturn of the CO-55 experimental/investigational denial;
2. Reprocessing of claim TEST-CLAIM-00070 in accordance with the applicable covered benefit provisions; and
3. Prompt payment of the denied amount of $2,550.13.

This appeal is submitted in advance of the appeal deadline of 2026-06-27. Should the reviewer require any additional clinical documentation or clarification, please contact our office promptly so that we may respond within the applicable timeframe.

Enclosures:
1. Peer-reviewed clinical guidelines supporting medical necessity of CPT 97819 and CPT 26021
2. Letter of medical necessity from treating physician
3. Clinical literature demonstrating standard-of-care status of the procedures at issue
4. Treatment plan and clinical notes documenting medical indication
5. Documentation of prior conservative treatment attempts, if applicable
6. Payer's clinical policy and coverage determination criteria for CPT 97819 and CPT 26021

Respectfully submitted,

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