Appeal — TEST-CLAIM-00097

Date: [Date of Submission]

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

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00097
Payer: Synthetic Medicaid-TX
Service Date: March 31, 2026
Denial Date: June 14, 2026
Denial Reason: CO-55 – Procedure/Treatment Deemed Experimental/Investigational
Procedure Codes: CPT 14847, CPT 48462
Diagnosis Code: M17.25
Denied Amount: $3,018.14
Appeal Deadline: July 14, 2026

Dear Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of [Hospital/Facility Name] regarding the denial of Claim TEST-CLAIM-00097, adjudicated by Synthetic Medicaid-TX on June 14, 2026. The claim was denied under CO-55, citing that the procedures billed — CPT 14847 (skin graft/flap surgery) and CPT 48462 (pancreatic-related procedure) — were deemed experimental or investigational by the payer. We respectfully but firmly contest this determination and request that the claim be reprocessed and the denied amount of $3,018.14 be paid in full.

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I. GROUNDS FOR APPEAL

The denial of these services as experimental or investigational is not supported by the available clinical evidence, applicable standards of care, or regulatory status of the procedures performed. The following arguments form the basis of this appeal:

• CPT 14847 and CPT 48462 Are Established, Non-Experimental Procedures
Both procedures billed on this claim are recognized, established techniques supported by peer-reviewed clinical literature and, where applicable, cleared or approved by the U.S. Food and Drug Administration (FDA). The payer's application of the experimental/investigational exclusion to these procedures is inconsistent with current accepted standards of medical practice. The enclosed clinical evidence and peer-reviewed literature substantiate that these procedures have moved well beyond investigational status and are routinely employed in appropriate clinical contexts.

• The Treating Physician Has Documented Medical Necessity
The treating physician has provided a letter of medical necessity explaining the clinical rationale for performing these procedures in connection with the patient's diagnosed condition. This documentation demonstrates that the services rendered were not elective, speculative, or experimental in nature, but were medically indicated and consistent with the individualized needs of the patient at the time of service.

• FDA Approval and Regulatory Clearance Support the Non-Experimental Designation
The enclosed FDA approval documentation or clearance records confirm the regulatory status of the technique or device utilized, further undermining the payer's characterization of these services as investigational. A procedure that has received FDA clearance or approval cannot appropriately be classified as experimental under standard payer policy definitions.

• The Operative Report Substantiates Medical Indication and Rebuts the Experimental Designation
We acknowledge that the payer may have questions regarding the clinical relationship between the procedures performed and the documented diagnosis of M17.25 (unilateral primary osteoarthritis, left knee). The enclosed operative report provides a detailed account of the medical indication, the clinical circumstances that necessitated these procedures, and the intraoperative findings that guided the treating physician's decisions. We respectfully direct the reviewer's attention to this document as the primary source for understanding the clinical context of the services rendered on March 31, 2026.

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II. APPLICABLE PAYER POLICY

Synthetic Medicaid-TX's experimental/investigational exclusion requires that a procedure lack sufficient clinical evidence, peer-reviewed support, or regulatory approval to be properly classified as experimental. As demonstrated by the enclosed documentation, CPT 14847 and CPT 48462 do not meet this standard for exclusion. The payer's denial fails to account for the established clinical evidence base supporting these procedures and does not adequately address the specific clinical circumstances documented in the medical record.

We further note that a blanket application of CO-55 without individualized review of the clinical evidence presented in the operative report and the physician's letter of medical necessity does not constitute a sufficient basis for denial under applicable Medicaid managed care appeal standards.

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III. ENCLOSED SUPPORTING DOCUMENTATION

In support of this appeal, the following documents are enclosed for the reviewer's consideration:

1. Letter of medical necessity from the treating physician
2. Operative report documenting the medical indication and procedures performed on March 31, 2026
3. Peer-reviewed clinical guidelines and/or literature supporting the medical necessity and established status of CPT 14847 and CPT 48462
4. FDA approval documentation or clearance status for the procedure(s) and/or technique(s) utilized
5. Prior authorization approval, if obtained prior to the date of service

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IV. REQUESTED REMEDY

Based on the foregoing arguments and supporting documentation, we respectfully request that Synthetic Medicaid-TX:

1. Overturn the denial issued on June 14, 2026, under CO-55 for Claim TEST-CLAIM-00097;
2. Reprocess the claim in full in accordance with the applicable fee schedule and covered benefits; and
3. Issue payment of the denied amount of $3,018.14 to [Hospital/Facility Name].

We trust that upon review of the enclosed clinical documentation, the payer will agree that the services rendered on March 31, 2026, were medically necessary, clinically appropriate, and not experimental or investigational in nature.

Should the reviewer require additional documentation or clarification, please do not hesitate to contact the undersigned at [Contact Name, Title, Phone Number, and Email Address].

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital/Facility Name]
[Address]
[Phone Number]
[Email Address]
[Date]