Appeal — TEST-CLAIM-00029

Date: [Date of Submission]

Synthetic Cigna
Appeals and Grievances Department
[Payer Address]

Re: Formal Appeal of Claim Denial
Claim Number: TEST-CLAIM-00029
Payer: Synthetic Cigna
Service Date: November 27, 2025
Procedure Codes: CPT 61990, CPT 35995
Diagnosis Code: F32.88
Denied Amount: $796.01
Denial Date: February 23, 2026
Appeal Deadline: June 23, 2026

Dear Synthetic Cigna Appeals and Grievances Department,

On behalf of [Facility Name], we are submitting this formal written appeal contesting the denial of Claim TEST-CLAIM-00029, issued by Synthetic Cigna on February 23, 2026. The claim was denied under adjustment reason code CO-197, citing the absence of precertification, authorization, or notification for services rendered on November 27, 2025. The denied amount subject to this appeal is $796.01 of the $1,028.25 total billed. We respectfully request that Synthetic Cigna overturn this denial, reprocess the claim, and remit payment for the denied amount in full.

I. BASIS FOR DENIAL AND GROUNDS FOR APPEAL

The denial asserts that precertification or prior authorization was absent for CPT 61990 (neurosurgical procedure) and CPT 35995 (vascular procedure), performed on November 27, 2025, under the primary diagnosis of F32.88 (depressive disorder, other specified). We dispute this denial on the grounds that prior authorization was, in fact, obtained and/or a timely notification was submitted to Synthetic Cigna in connection with these services. The CO-197 denial therefore does not accurately reflect the authorization status of this claim.

As detailed below, the enclosed supporting documentation directly rebuts the assertion that precertification was absent.

II. SUPPORTING EVIDENCE

The following documents are enclosed with this appeal and collectively demonstrate that the prior authorization requirement was satisfied:

1. Prior Authorization Approval Letter or Certificate — This document confirms that authorization was secured from Synthetic Cigna for the procedures in question. It directly contradicts the CO-197 denial assertion that precertification was absent.

2. Precertification Request Documentation — This record establishes that a formal request for precertification was submitted to Synthetic Cigna in advance of or in connection with the November 27, 2025 service date, demonstrating the facility's compliance with the payer's authorization process.

3. Physician's Letter of Medical Necessity — The enclosed letter of medical necessity, authored by the treating physician, documents the clinical rationale supporting the performance of CPT 61990 and CPT 35995 for the patient's diagnosed condition (F32.88). This letter further substantiates that the services were medically necessary and appropriately ordered.

4. Clinical Notes from the Service Date — The clinical notes from November 27, 2025 provide contemporaneous documentation of the patient's condition, the procedures performed, and the clinical decision-making that necessitated these services.

5. Proof of Timely Authorization Submission — Enclosed records demonstrate that the authorization request or notification was submitted to Synthetic Cigna within the timeframes required under the applicable policy.

6. Communication Records with Payer Regarding Authorization Status — Copies of any correspondence or communication between our facility and Synthetic Cigna regarding the authorization status of this claim are included to provide a complete record of the authorization process.

III. APPLICABLE POLICY AND CONTRACTUAL BASIS

Synthetic Cigna's prior authorization policy requires that precertification be obtained for designated procedures prior to or in connection with service delivery. As set forth in the enclosed documentation, our facility complied with this requirement for CPT 61990 and CPT 35995. The CO-197 denial code is therefore inapplicable to this claim, as it presupposes that no authorization activity occurred. The enclosed records refute this premise.

Furthermore, we note that even in circumstances where advance authorization may not have been fully secured prior to service delivery, Synthetic Cigna's policies and applicable regulations may provide for exceptions based on extenuating clinical circumstances or evidence of good-faith payer communication. The enclosed documentation addresses these alternative grounds to the extent applicable.

IV. REQUESTED REMEDY

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

1. Overturn the CO-197 denial issued on February 23, 2026, with respect to Claim TEST-CLAIM-00029;
2. Reprocess the claim for CPT 61990 and CPT 35995, rendered on November 27, 2025, in accordance with the applicable plan benefits and contracted rates; and
3. Remit payment of the denied amount of $796.01 promptly upon completion of reprocessing.

V. CONCLUSION

Our facility is committed to working collaboratively with Synthetic Cigna to resolve this matter. The enclosed documentation provides clear and substantive evidence that the prior authorization requirement was met and that the CO-197 denial should be overturned. We trust that upon review of the complete appeal record, Synthetic Cigna will agree that reprocessing and payment of this claim is warranted.

Should you require any additional information or documentation in connection with this appeal, please contact our Appeals and Denials Department at [Facility Contact Information].

Respectfully submitted,

[Authorized Facility Representative Name]
[Title]
[Facility Name]
[Facility Address]
[Facility NPI]
[Phone Number]
[Date]

Enclosures:
- Prior Authorization Approval Letter or Certificate
- Precertification Request Documentation
- Physician's Letter of Medical Necessity
- Clinical Notes from Service Date (November 27, 2025)
- Proof of Timely Authorization Submission
- Communication Records with Payer Regarding Authorization Status