Appeal — TEST-CLAIM-00091

Date: [Date of Submission]

Via: [Submission Method]

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

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00091
Internal Claim Reference: e2facd22-7224-45f8-9a02-6dd31cad234e
Service Date: April 22, 2026
Denial Date: June 19, 2026
Denied Amount: $5,361.06
Appeal Deadline: September 17, 2026

Dear Synthetic BCBS-TX Appeals Department,

This letter constitutes a formal first-level appeal on behalf of our facility regarding the above-referenced claim, which was denied on June 19, 2026, under denial code CO-55: "Procedure/treatment is deemed experimental/investigational by the payer." We respectfully request that Synthetic BCBS-TX overturn this denial, reprocess the claim, and issue payment for the denied amount of $5,361.06.

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I. BACKGROUND AND BASIS FOR DENIAL

On April 22, 2026, our facility provided surgical services billed under CPT codes 40903 (mouth/tongue surgery) and 60615 (thyroid/parathyroid surgery) in connection with the patient's diagnosis of other specified urinary incontinence (ICD-10: N39.28). The total billed amount for the claim was $9,282.93, of which $5,361.06 was denied. Synthetic BCBS-TX's stated basis for denial is that the procedures in question are experimental or investigational in nature.

We respectfully but firmly disagree with this characterization and submit that the denial is both clinically and contractually unsupported.

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II. GROUNDS FOR APPEAL

A. CPT Codes 40903 and 60615 Are Established, Accepted Surgical Procedures

CPT codes 40903 and 60615 are recognized procedure codes maintained by the American Medical Association (AMA) representing established surgical techniques for mouth/tongue and thyroid/parathyroid interventions, respectively. The inclusion of a procedure within the AMA CPT code set is itself indicative of broad clinical recognition and mainstream adoption. Procedures that are truly experimental or investigational are typically not assigned permanent CPT codes and are instead represented by Category III (emerging technology) codes. The fact that both procedures carry permanent Category I CPT designations strongly contradicts any characterization of these services as experimental or investigational.

B. The Payer's Experimental/Investigational Designation Lacks Sufficient Clinical Basis

Under Synthetic BCBS-TX's own experimental/investigational exclusion policy, a procedure may only be appropriately excluded when it lacks sufficient clinical evidence, peer-reviewed support, or regulatory clearance to be considered standard of care. As documented in the enclosed supporting materials, both CPT 40903 and CPT 60615 are supported by peer-reviewed clinical literature, published efficacy data, and medical society standards of care. The enclosed peer-reviewed clinical guidelines, published clinical evidence or meta-analyses, and medical society guidelines or standards of care statements collectively demonstrate that these procedures represent accepted, non-experimental treatment modalities. Where applicable, FDA clearance or approval documentation further supports the established status of the interventions provided.

C. Medical Necessity for the Patient's Diagnosis Was Clearly Established

The treating physician determined that the services rendered on April 22, 2026, were medically necessary for the management of the patient's condition as identified under ICD-10 diagnosis N39.28 (other specified urinary incontinence). The enclosed letter of medical necessity from the treating physician details the clinical rationale supporting the procedures performed. Additionally, the enclosed peer-to-peer review notes or physician correspondence further substantiate the clinical judgment exercised in recommending and performing these services.

D. The Denied Amount Is Recoverable Under the Plan

Given that the procedures at issue are established and non-experimental, the payer's invocation of the experimental/investigational exclusion as the basis for denying $5,361.06 is not contractually supported. There is no valid basis under the applicable policy to withhold reimbursement for services that are recognized as standard of care by mainstream clinical and regulatory authorities.

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III. SUPPORTING DOCUMENTATION ENCLOSED

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. Peer-reviewed clinical guidelines or position statements supporting CPT codes 40903 and 60615
3. Published clinical evidence or meta-analyses demonstrating procedural efficacy
4. FDA approval documentation or clearance letter (where applicable)
5. Medical society guidelines or standards of care statements
6. Peer-to-peer review notes or physician correspondence

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IV. REQUESTED REMEDY

Based on the foregoing, we respectfully request that Synthetic BCBS-TX:

1. Overturn the June 19, 2026 denial of claim TEST-CLAIM-00091 in its entirety;
2. Reprocess the claim consistent with the patient's applicable benefits and the contractual fee schedule; and
3. Issue payment of the denied amount of $5,361.06 promptly upon completion of reprocessing.

Should Synthetic BCBS-TX require additional clinical information or wish to arrange a physician-to-physician peer-to-peer review, we welcome the opportunity and ask that our facility be contacted at the information provided below.

This appeal is submitted in advance of the September 17, 2026 appeal deadline. We trust that upon thorough review of the clinical and policy documentation enclosed, Synthetic BCBS-TX will concur that the experimental/investigational designation is not applicable to the services provided and that the denied amount should be released for payment.

Thank you for your prompt attention to this matter.

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Phone Number]
[Fax Number]
[Email Address]
[NPI / Tax ID, as applicable]