Appeal — TEST-CLAIM-00090

Date: [Date of Submission]

Via: [Payer Appeals Submission Method]

Synthetic Humana
Appeals & Grievances Department
[Payer Address]

RE: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00090
Internal Claim ID: 2bb90e8e-bee9-4e6c-abe0-0f02f17f529a
Payer: Synthetic Humana
Date of Service: May 26, 2026
Procedure Code(s): CPT 31012
Diagnosis Code(s): R07.65, I10.55
Billed Amount: $5,850.31
Denied Amount: $2,265.68
Denial Date: June 22, 2026
Appeal Deadline: August 21, 2026

Dear Synthetic Humana Appeals Department,

This letter constitutes a formal first-level appeal on behalf of the treating facility regarding the denial of External Claim ID TEST-CLAIM-00090, issued on June 22, 2026. We respectfully request that Synthetic Humana overturn this denial and reprocess the claim for payment of the denied amount of $2,265.68.

I. DENIAL REASON

The claim was denied under reason code CO-252, which indicates that an attachment or additional documentation was required to adjudicate the claim. Critically, this denial does not represent a finding that the services rendered were medically unnecessary, non-covered, or improperly coded. Rather, the claim was suspended solely on the basis that supporting documentation had not been received by the payer at the time of initial adjudication.

II. BASIS FOR APPEAL

We respectfully assert that the documentation necessary to establish the medical necessity of CPT 31012 (nasal/sinus endoscopy with surgical intervention), performed on May 26, 2026, is available in full and is enclosed with this appeal. The denial should be overturned on the following grounds:

• The CO-252 denial is administrative in nature — not a clinical or coverage-based determination — and is fully resolved by the submission of the enclosed supporting documentation.

• The operative report enclosed with this appeal directly documents the procedure performed under CPT 31012 and establishes the clinical rationale and medical necessity for the surgical endoscopic intervention.

• The anesthesia record, clinical notes, patient history and physical examination notes, and progress notes from the date of service (May 26, 2026) further corroborate the appropriateness of the services rendered in the context of the patient's presenting diagnoses (R07.65 and I10.55).

• Synthetic Humana's own documentation submission policy, as reflected in the CO-252 denial rationale, confirms that adjudication of this claim is contingent upon receipt of the required attachments — not upon any coverage exclusion or medical necessity determination. Submission of the enclosed documentation directly satisfies the stated basis for denial.

III. ENCLOSED SUPPORTING DOCUMENTATION

The following documents are enclosed with this appeal to satisfy the payer's documentation requirement and support the medical necessity of the services billed:

1. Operative report for CPT 31012 (date of service: May 26, 2026)
2. Anesthesia record (date of service: May 26, 2026)
3. Clinical documentation supporting medical necessity
4. Patient history and physical examination notes
5. Progress notes from the date of service
6. Imaging reports (if applicable to the airway endoscopy performed)

These documents collectively establish that the endoscopic procedure was medically indicated, appropriately performed, and correctly coded in accordance with the patient's documented clinical condition.

IV. REQUESTED REMEDY

We respectfully request that Synthetic Humana:

1. Accept and review the enclosed documentation in satisfaction of the CO-252 documentation requirement;
2. Reprocess External Claim ID TEST-CLAIM-00090 in full; and
3. Issue payment of the denied amount of $2,265.68 in accordance with the applicable contractual terms and fee schedule.

Given that this denial is purely administrative and the underlying documentation substantiates both the performance and medical necessity of the billed service, we are confident that a review of the enclosed records will support full adjudication and payment of this claim.

Should the Appeals Department require any additional information or clarification, please contact our billing department at [Facility Contact Information]. We appreciate your prompt attention to this matter and request a written determination within the timeframe specified under applicable state and federal appeal regulations.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Facility NPI]
[Contact Phone Number]
[Contact Email Address]

Enclosures: As listed in Section III above