Appeal — TEST-CLAIM-00038

Date: [Date of Submission]

To: Appeals and Grievances Department
Synthetic UHC

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00038
Service Date: February 6, 2026
Denial Date: May 3, 2026
Denied Amount: $731.32
Appeal Deadline: August 1, 2026

Dear Appeals and Grievances Representative,

This letter constitutes a formal appeal on behalf of the billing/rendering provider regarding the denial of Claim TEST-CLAIM-00038, submitted to Synthetic UHC for services rendered on February 6, 2026. We respectfully request that this denial be overturned and that the claim be reprocessed for payment of the denied amount of $731.32.

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I. BACKGROUND AND DENIAL REASON

The above-referenced claim was submitted for services provided on February 6, 2026, encompassing the following procedure codes: CPT 91057, CPT 39581, and CPT 78494, rendered in connection with the patient's diagnoses of R07.56 (chest pain) and K21.75 (gastroesophageal reflux disease with esophageal damage). The total billed amount for the claim was $1,236.76, of which $731.32 was denied.

The denial was issued on May 3, 2026, under reason code CO-226: "Information requested from the billing/rendering provider was not provided." It is our position that this denial should be overturned in full, as the underlying clinical documentation and supporting records exist and are being provided herewith to cure the identified deficiency.

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II. BASIS FOR APPEAL

CO-226 denials are issued when a payer has requested specific information from a provider and that information was not received within the required timeframe. This denial does not reflect a determination that the services were not medically necessary, not covered, or improperly billed — it reflects solely a documentation gap. That gap is now being remedied through this appeal.

The procedures billed — CPT 91057, CPT 39581, and CPT 78494 — were performed on February 6, 2026, in response to the patient's clinically documented diagnoses of chest pain (R07.56) and GERD with esophageal damage (K21.75). Complete clinical records, procedure documentation, and physician notes exist for this date of service and are enclosed with this appeal to directly address the payer's documentation requirement.

Pursuant to Synthetic UHC's documentation submission requirements applicable to CO-226 denials, a provider has the right and opportunity to supply the requested information through the formal appeals process. The enclosed documentation satisfies the informational request that served as the sole basis for the denial.

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III. SUPPORTING DOCUMENTATION

The following documents are enclosed with this appeal to address the payer's documentation request and substantiate the medical necessity and appropriateness of the billed services:

1. Medical records from the date of service (February 6, 2026), including all relevant clinical notes and assessments;
2. Operative report and/or procedure documentation specific to CPT codes 91057, 39581, and 78494;
3. Attending physician's clinical notes supporting the medical necessity of the procedures performed;
4. Itemized billing statement or detailed superbill reflecting the services rendered;
5. Any prior authorization or predetermination correspondence on file relevant to the date of service; and
6. The enclosed response letter directly addressing the specific information requested by Synthetic UHC in connection with this denial.

Together, these documents demonstrate that the services were medically necessary, clinically appropriate, and properly documented, and that the provider is in full compliance with Synthetic UHC's documentation submission requirements.

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IV. REQUESTED REMEDY

For the reasons set forth above, we respectfully request that Synthetic UHC:

1. Accept the enclosed documentation as satisfying the informational request underlying the CO-226 denial;
2. Overturn the denial of Claim TEST-CLAIM-00038 in its entirety; and
3. Reprocess the claim for payment of the full denied amount of $731.32 in accordance with the applicable contractual and plan terms.

This appeal is being submitted in advance of the August 1, 2026 appeal deadline. Should additional information be required to complete the review of this appeal, please contact our office at the earliest opportunity so that we may respond promptly.

We appreciate your attention to this matter and look forward to a timely and favorable resolution.

Respectfully submitted,

[Authorized Signature]
[Name and Title of Authorized Representative]
[Facility/Practice Name]
[Address]
[Phone Number]
[Fax Number]
[Date]

Enclosures:
- Medical records from February 6, 2026
- Operative/procedure report for CPT 91057, 39581, 78494
- Physician clinical notes (medical necessity)
- Itemized billing statement
- Prior authorization/predetermination correspondence (if applicable)
- Response letter addressing payer's specific documentation request