Appeal — TEST-CLAIM-00075

Date: [Letter Date]

Synthetic Aetna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
External Claim ID: TEST-CLAIM-00075
Claim ID (Internal): e4c6f18d-a995-476a-8cae-e6ee3d18cc34
Payer: Synthetic Aetna
Date of Service: December 2, 2025
Denial Date: March 1, 2026
Denied Amount: $929.60
Procedure Codes: CPT 88554, CPT 17180
Diagnosis Code: J45.38
Appeal Deadline: August 28, 2026

Dear Synthetic Aetna Appeals and Grievances Department,

This letter constitutes a formal first-level appeal on behalf of the above-referenced provider against the denial issued on March 1, 2026, for services rendered on December 2, 2025. We respectfully request that Synthetic Aetna overturn this denial, reprocess Claim TEST-CLAIM-00075 in full, and remit payment of the denied amount of $929.60.

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I. REASON FOR DENIAL AND BASIS FOR APPEAL

Synthetic Aetna denied $929.60 of the total billed amount of $2,801.74 under adjustment reason code CO-252, citing that an attachment or other documentation is required to adjudicate the claim. The procedures at issue are CPT 88554 (anatomic pathology) and CPT 17180 (destruction/removal of lesion), billed in connection with diagnosis code J45.38.

The provider respectfully asserts that this denial is administrative in nature and fully curable. The payer has not determined that the services were medically unnecessary, excluded from coverage, or otherwise ineligible for reimbursement. Rather, the sole basis for denial is the absence of supporting documentation. That documentation exists, has been compiled, and is enclosed with this appeal.

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II. SUPPORTING DOCUMENTATION ENCLOSED

In direct response to the CO-252 denial and in accordance with Synthetic Aetna's documentation and attachment requirements for claim adjudication, the following supporting documents are enclosed with this appeal:

1. Pathology specimen report from the date of service, documenting the tissue or specimen evaluated under CPT 88554;
2. Operative report / procedure note from the date of service, documenting the performance of CPT 17180 and the clinical circumstances necessitating the procedure;
3. Histopathology results supporting the medical appropriateness of the pathology services billed;
4. Clinical notes from the date of service (December 2, 2025), providing the full clinical context and supporting the medical necessity of both procedures;
5. Physician's letter of medical necessity, affirming that the services rendered were clinically indicated for the patient's condition; and
6. Prior authorization documentation, if applicable, demonstrating any pre-service approvals obtained.

These documents collectively establish that the services were medically necessary, accurately coded, and appropriately billed. The sole deficiency identified by the payer — the absence of attached documentation — is remedied by this submission.

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III. POLICY BASIS FOR REVERSAL

Synthetic Aetna's own adjudication policy governing CO-252 denials contemplates that claims denied solely for missing attachments are curable upon submission of the requested records. The denial does not reflect a coverage exclusion, a finding of medical inappropriateness, or a billing irregularity. Because the underlying services are covered benefits and the required documentation is now provided, there is no remaining basis to withhold payment.

CPT 88554 and CPT 17180 are recognized, reimbursable procedure codes. The procedures were performed on December 2, 2025, by a qualified provider. The enclosed clinical documentation supports both the medical necessity and the accuracy of the coding submitted on this claim.

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IV. REQUESTED REMEDY

The provider respectfully requests that Synthetic Aetna:

1. Accept and review the enclosed documentation in connection with Claim TEST-CLAIM-00075;
2. Reprocess the claim in full upon confirmation that the documentation satisfies adjudication requirements; and
3. Remit payment of the denied amount of $929.60, consistent with the applicable contracted rate and plan benefits.

Should Synthetic Aetna require any additional information or clarification, please contact the provider's billing department at the contact information listed below. We ask that this appeal be acknowledged and adjudicated within the timeframes required by applicable state and federal regulations and the terms of the provider agreement.

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Thank you for your prompt attention to this matter. The provider remains committed to resolving this claim in good faith and trusts that review of the enclosed documentation will result in full payment.

Respectfully submitted,

[Provider Name / Facility Name]
[Provider Address]
[Provider Phone Number]
[Provider NPI]
[Billing Contact Name and Title]

Enclosures:
- Pathology specimen report
- Operative report / procedure note
- Histopathology results
- Clinical notes from date of service (2025-12-02)
- Physician's letter of medical necessity
- Prior authorization documentation (if applicable)