Appeal — TEST-CLAIM-00032

Date: [Insert Date of Submission]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00032
Payer: Synthetic Aetna
Date of Service: 2025-10-30
Procedure Codes: CPT 54092, CPT 13761
Diagnosis Codes: ICD-10 N39.23, R07.27
Denied Amount: $1,035.56
Denial Date: 2026-01-09
Appeal Deadline: 2026-07-08

Dear Synthetic Aetna Appeals and Grievances Department,

On behalf of our facility, we are submitting this formal appeal contesting the denial issued on 2026-01-09 for claim number TEST-CLAIM-00032, covering services rendered on 2025-10-30. Synthetic Aetna denied $1,035.56 of the total billed amount of $1,423.98 under denial reason CO-4, asserting that the procedure code(s) billed are inconsistent with the modifier(s) used. We respectfully disagree with this determination and request that the claim be reprocessed and payment issued for the denied amount.

I. GROUNDS FOR APPEAL

The CO-4 denial is based on an alleged incompatibility between the procedure codes billed — CPT 54092 and CPT 13761 — and the modifier(s) applied to the claim. It is our position that this denial is not supported by the clinical and coding documentation on record, and that the modifier as applied accurately and appropriately qualifies the procedures as performed on the date of service.

Specifically, our appeal rests on the following grounds:

  • The operative report clearly documents the procedures performed on 2025-10-30 and supports the selection of CPT 54092 and CPT 13761 as the correct procedure codes for the services rendered.
  • The modifier applied is clinically and procedurally appropriate to the billed CPT codes and does not constitute an incompatible pairing under applicable coding guidelines; the enclosed modifier documentation and clarification letter provide a detailed explanation of the relationship between the modifier and the procedure codes.
  • The clinical documentation, including anatomical and procedural details, demonstrates that the modifier was used to accurately describe the specific circumstances under which the procedures were performed, consistent with the intent and appropriate application of the modifier as defined by CPT coding conventions.
  • Synthetic Aetna's own policy basis for procedure code and modifier compatibility requires an evaluation of the clinical record; the supporting documentation enclosed herewith establishes that the modifier-to-procedure-code pairing is valid and that the denial does not withstand scrutiny when reviewed against the complete medical record.

II. SUPPORTING DOCUMENTATION

In support of this appeal, we have enclosed the following documentation:

  1. Operative report detailing the specific procedure(s) performed on 2025-10-30
  2. Clinical documentation supporting medical necessity for CPT 54092 and CPT 13761
  3. Modifier documentation and clarification letter explaining the relationship between the procedure code(s) and the modifier used
  4. Anatomical and procedural details justifying code selection and modifier applicability

We respectfully request that the reviewing clinician or coding specialist at Synthetic Aetna carefully evaluate these enclosed documents in their entirety before rendering a determination on this appeal.

III. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic Aetna:

  1. Overturn the CO-4 denial issued on 2026-01-09 for claim number TEST-CLAIM-00032;
  2. Reprocess the claim in full, recognizing CPT 54092 and CPT 13761 with the applied modifier(s) as submitted; and
  3. Issue payment of the denied amount of $1,035.56 in accordance with the applicable contractual rates and benefit provisions.

Should additional information be required to complete the review of this appeal, please do not hesitate to contact our facility's billing and appeals department at [Insert Contact Information]. We appreciate your prompt attention to this matter and look forward to a favorable resolution.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]