Appeal — TEST-CLAIM-00064

[Hospital Letterhead]

Date: [Date of Submission]

Appeals Department
Synthetic Humana
[Payer Address]

RE: Formal Appeal of Claim Denial — Claim No. TEST-CLAIM-00064
Service Date: April 17, 2026
Denial Date: May 30, 2026
Denial Reason: CO-252 — Attachment/Documentation Required
Billed Amount: $2,185.24 | Denied Amount: $2,033.09
Appeal Deadline: July 29, 2026

Dear Synthetic Humana Appeals Department,

On behalf of [Hospital Name] (hereinafter "the Facility"), we respectfully submit this formal appeal contesting the denial issued on May 30, 2026, for claim number TEST-CLAIM-00064. This claim pertains to services rendered on April 17, 2026, and was denied under CO-252, indicating that an attachment or other documentation is required to adjudicate the claim. The Facility respectfully asserts that this denial should be overturned and the claim reprocessed for payment upon review of the enclosed supporting documentation.

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I. BACKGROUND AND BASIS FOR APPEAL

The Facility provided medically necessary services on April 17, 2026, including a colonoscopy with high-risk lesion removal or ablation (CPT 46342), rendered to a patient with a documented diagnosis (ICD-10 I10.69). The claim was submitted to Synthetic Humana for reimbursement in the amount of $2,185.24. On May 30, 2026, Synthetic Humana issued a denial under CO-252, indicating that adjudication could not be completed due to the absence of required documentation.

It is important to note that a CO-252 denial does not constitute a determination that the services rendered were not covered or not medically necessary. Rather, it reflects a suspension of adjudication pending receipt of supporting documentation. As such, the underlying claim has never been evaluated on its merits, and the Facility respectfully requests that Synthetic Humana complete a full substantive review upon receipt of the enclosed records.

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II. SUPPORTING DOCUMENTATION

In accordance with Synthetic Humana's documentation submission requirements, the Facility is enclosing all documentation necessary to support full adjudication of this claim. The following records are enclosed with this appeal:

1. Operative Report — detailing the procedure performed on April 17, 2026, including the nature of the colonoscopy and therapeutic intervention conducted under CPT 46342.

2. Clinical Documentation Supporting Medical Necessity — including clinical notes that document the clinical indication for the procedure and the physician's rationale for performing a colonoscopy with high-risk lesion removal or ablation.

3. Pre-Operative Assessment and Patient History — documenting the patient's relevant medical history and clinical status at the time the procedure was ordered and performed.

4. Imaging Reports or Diagnostic Studies — supporting the diagnostic workup that preceded and justified the procedure.

5. Pathology Report (if applicable) — providing findings from any tissue specimens obtained during the procedure.

6. Anesthesia Record — documenting anesthesia administration in conjunction with the procedure.

7. Hospital Discharge Summary — summarizing the patient's clinical course and disposition following the April 17, 2026, encounter.

Together, these documents satisfy the documentation requirements identified under Synthetic Humana's applicable policy and provide a complete clinical record demonstrating that the services billed under CPT 46342 were medically necessary and appropriately rendered.

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III. POLICY BASIS FOR APPEAL

Synthetic Humana's own documentation submission policy acknowledges that a CO-252 denial is a suspension of adjudication — not a coverage or medical necessity determination. The Facility's submission of the complete documentation package described above directly addresses and satisfies the payer's stated basis for denial. There is no substantive clinical or coverage dispute that would independently preclude payment; the sole impediment to adjudication was the absence of documentation, which is now remedied by this appeal submission.

Accordingly, the Facility respectfully requests that Synthetic Humana adjudicate this claim on its merits in full, consistent with the patient's applicable benefit plan and the supporting clinical record provided herein.

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IV. REQUESTED REMEDY

The Facility respectfully requests that Synthetic Humana:

1. Accept and review the enclosed documentation in its entirety;
2. Reprocess claim number TEST-CLAIM-00064 for services rendered on April 17, 2026; and
3. Issue payment of the denied amount of $2,033.09 in accordance with the patient's plan benefits and the Facility's contractual agreement with Synthetic Humana.

This appeal is being submitted in advance of the July 29, 2026, appeal deadline. Should Synthetic Humana require any additional information to complete its review, please contact the Facility's Revenue Cycle/Appeals Department at [Hospital Contact Information].

Thank you for your prompt attention to this matter. The Facility trusts that a thorough review of the enclosed documentation will demonstrate that all conditions for payment have been met and that reimbursement is warranted.

Respectfully submitted,

[Authorized Signatory Name]
[Title]
[Hospital Name]
[Address]
[Phone Number]
[Fax Number]
[Email Address]

Enclosures:
- Operative Report
- Clinical Documentation Supporting Medical Necessity
- Pre-Operative Assessment and Patient History
- Imaging Reports or Diagnostic Studies
- Pathology Report (if applicable)
- Anesthesia Record
- Hospital Discharge Summary