Read the actual letter before you pay for one.

Marcus Webb, MD
Hill Country Orthopedics & Primary Care
1204 Medical Parkway, Suite 140
Kerrville, TX 78028
Phone: (830) 555-0182
NPI: 1379325990

June 18, 2026

Novitas Solutions, Inc. (Jurisdiction JH)
Medicare Redetermination / Appeals Department

RE: Request for redetermination (first-level Medicare appeal)
Claim Number: MCR26TX77345210
Patient: [PATIENT NAME]
Medicare ID: [MEMBER ID]
Date of Service: April 7, 2026
CPT Code at Issue: 99213, modifier 25
Diagnoses: I10; M17.11
Denial Code: CO-97 (RARC M15)
Denial Date: May 5, 2026
Amount in Dispute: the applicable Medicare allowed amount for CPT 99213 (charge submitted: $128.00)

To the Redetermination Department:

On behalf of Hill Country Orthopedics & Primary Care, I formally request redetermination of the above claim. The evaluation and management service reported as CPT 99213 with modifier 25 on the April 7, 2026 date of service was denied on May 5, 2026 under CO-97 with remark M15, on the basis that the benefit for this service is included in the payment or allowance for another service already adjudicated. I respectfully ask that this determination be reversed and that the line be reprocessed and paid at the applicable Medicare fee-schedule allowed amount. This request is submitted within the 120-day redetermination window and is filed on or before September 2, 2026.

This denial reflects a bundling of the office visit (99213) into the joint injection procedure (20610) that were both furnished on the same date. The controlling correct-coding authority does not support that result. Per the CMS National Correct Coding Initiative Practitioner Procedure-to-Procedure edits, an active PTP edit pairs column 1 code 20610 with column 2 code 99213, with the column 2 code being the one denied when the pair is billed together. [1] Critically, however, this edit is not an absolute prohibition on separate payment. The edit carries modifier indicator 1, meaning a modifier is allowed and separate payment is permitted with an appropriate modifier — for example, 25, 59, or an X{EPSU} modifier — when clinically justified. [1] This edit has been in effect since October 1, 2020 under release v322r0. [1] Because the indicator is 1, the proper inquiry is not whether the services can ever be paid separately, but whether the documentation supports a clinically distinct, separately identifiable service. Here it does.

The two services addressed separate and unrelated clinical problems. The procedure (20610) was directed at the patient's knee condition (M17.11), while the separately identifiable evaluation and management service was furnished for a distinct condition — essential hypertension (I10). These represent a separate injury or condition, each supported by its own diagnosis, and the office record contains distinct E/M documentation apart from the work inherent in the injection. The use of modifier 25 on the 99213 line correctly signaled that the E/M service was significant and separately identifiable from the procedure performed the same day. Given the differing diagnoses and the independent E/M documentation, the office visit was not subsumed by the pre- and post-service work intrinsic to CPT 20610 and qualifies for separate payment under the modifier-1 exception.

Because this matter turns on the documented distinctness of the E/M service rather than on any blanket NCCI prohibition, the conditions the edit itself recognizes for separate payment are satisfied. I therefore ask that the column 2 line be released from the bundle and adjudicated on its own merits.

This request is made under the Medicare Part B fee-for-service redetermination process. As the first level of appeal, it is filed with the Medicare Administrative Contractor for this jurisdiction within the applicable 120-calendar-day period following the initial determination. Should the redetermination uphold the denial in whole or in part, the practice reserves its right to pursue the next level of Medicare appeal (reconsideration by a Qualified Independent Contractor).

Accordingly, I request that Novitas Solutions overturn the CO-97 denial, reprocess CPT 99213 (modifier 25) for the April 7, 2026 date of service as a separately payable service, and remit payment at the applicable Medicare allowed amount. Please provide a written redetermination decision within the timeframe prescribed for Part B redeterminations. If any additional documentation would assist the review, please contact the practice at the number above; I am also available to discuss the clinical and coding basis of this service.

Enclosures:
- Explanation of Benefits / Medicare Remittance Advice for claim MCR26TX77345210
- Office notes for the April 7, 2026 date of service

[PHYSICIAN SIGNATURE]
Marcus Webb, MD
NPI: 1379325990
June 18, 2026

References

[1] CMS National Correct Coding Initiative (NCCI), Practitioner PTP Edits, release v322r0. Available at: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits

Robert Ellis, MD
Maple Grove Family Practice
780 High Street, Suite 110
Columbus, OH 43215
Phone: (614) 555-0188
NPI: 1379325990

June 18, 2026

UnitedHealthcare
Grievance and Appeals Department

RE: First-level internal appeal — Claim No. UHC26OH33920514
Patient: [PATIENT NAME] | Member ID: [MEMBER ID]
Date of service: January 12, 2026
CPT code: 99213 | Diagnosis: J06.9
Denial code: CO-29 ("The time limit for filing has expired"), denied May 2, 2026
Amount charged: $130.00 (reprocessing and payment requested at the applicable allowed amount)

To the Grievance and Appeals Department:

On behalf of Maple Grove Family Practice, I formally appeal and request reconsideration of the above-referenced claim, which UnitedHealthcare denied on May 2, 2026 under code CO-29 with the stated reason "The time limit for filing has expired." I respectfully request that the denial be overturned and that the claim be reprocessed and paid at the applicable allowed amount under the member's plan. This appeal is submitted within the applicable 180-day appeal window and on or before the file-by date of October 29, 2026, and is therefore timely.

The denial rests on a factual premise that is incorrect. This claim was submitted within the plan's timely-filing period, and I enclose documentary proof of that submission. Our records include a clearinghouse acceptance/timestamp report and a 277CA claim acknowledgment reflecting that the claim for the January 12, 2026 date of service was transmitted and accepted into the payer's intake within the filing window. The 277CA acknowledgment, with its associated Transaction Control Number, establishes the date the claim was received for adjudication. Because the electronic acknowledgment confirms receipt within the allowable period, the CO-29 determination appears to reflect an adjudication or intake-routing error rather than an actual late filing.

To the extent any portion of the processing delay is attributable to the original claim having been misdirected or held within the payer's intake systems, that circumstance constitutes payer-side error and supports a good-cause exception to any timely-filing limitation. The treating practice acted diligently and submitted the claim on time, as the enclosed EDI artifacts demonstrate; the practice should not bear the consequence of a routing or adjudication error it did not cause.

This claim arises under a self-funded employee benefit plan governed by ERISA. The plan is obligated to provide adequate written notice setting forth the specific reasons for any denial, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and afford a reasonable opportunity for a full and fair review by the appropriate named fiduciary of the decision denying the claim. [1] The denial notice here identifies only an expired filing limit — a reason directly contradicted by the enclosed proof of timely submission — and accordingly does not withstand the full and fair review to which this claim is entitled. On review, the plan's claims procedures must provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. [2] I ask that the enclosed clearinghouse and 277CA documentation be made part of the record and given full consideration on review.

Should the denial be upheld notwithstanding the documentary evidence of timely filing, the practice reserves the member's and its rights, including the right of a participant or beneficiary to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan. [3]

For the reasons above, I request that UnitedHealthcare reverse the CO-29 denial, reprocess Claim No. UHC26OH33920514, and remit payment at the applicable allowed amount under the member's plan. I ask for a written determination on this appeal within 30 days, or within the period required by the applicable plan procedures. If the denial is maintained, please provide the specific plan provision relied upon and a statement of any further internal appeal rights so that those rights may be exercised within the applicable deadline.

Enclosures:
- Clearinghouse acceptance/timestamp report
- 277CA claim acknowledgment
- Explanation of Benefits dated May 2, 2026

[PHYSICIAN SIGNATURE]
Robert Ellis, MD
NPI: 1379325990
June 18, 2026

References

[1] 29 U.S.C. §1133 (ERISA §503) - Claims procedure — notice and full and fair review. Available at: https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1133
[2] 29 CFR §2560.503-1 - Claims procedure requirements for employee benefit plans (ERISA). Available at: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-L/part-2560/section-2560.503-1
[3] 29 U.S.C. §1132 (ERISA §502(a)(1)(B)) - Civil enforcement — right of action to recover benefits. Available at: https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1132

David R. Okonkwo, MD
Movement Disorders Neurosurgery Center
6400 Fannin Street, Suite 2400
Houston, TX 77030
Phone: (713) 555-0182
NPI: 1379246808

June 27, 2026

Cigna
Grievance and Appeals Department

RE: First-level internal appeal — Request for reconsideration of denied claim
Claim Number: CIG2026041590233
Patient: [PATIENT NAME]
Member ID: [MEMBER ID]
CPT Code: 0398T (MR-guided focused ultrasound, thalamotomy)
Date of Service: March 9, 2026
Denial Code: CO-55 — "Deemed experimental or investigational"
Amount in dispute: the applicable allowed amount for CPT 0398T (charge submitted: $12,400.00)

To the Grievance and Appeals Department:

On behalf of the above-identified patient, this practice formally appeals and requests reconsideration of the denial of claim CIG2026041590233. In its determination dated April 15, 2026, Cigna denied CPT 0398T under code CO-55, stating that "This procedure is considered experimental/investigational for the reported condition and is therefore not covered." We respectfully request that Cigna overturn this denial and reprocess the claim for payment at the applicable allowed amount. This appeal is submitted within the plan's applicable appeal window; we ask that the exact filing deadline be confirmed against the denial notice.

The basis for the denial is incorrect as applied to this service and this indication. The denied procedure is MR-guided focused ultrasound thalamotomy, performed for the patient's documented diagnosis of essential tremor (ICD-10 G25.0). A service is properly classified as experimental or investigational only where it lacks final marketing authorization from the U.S. Food and Drug Administration for the indication at issue and lacks support in the peer-reviewed scientific literature and recognized clinical standards. This service satisfies each of those criteria, and the CO-55 determination cannot be sustained under any reasonable application of that standard.

First, the device used to perform this procedure holds full FDA Premarket Approval for precisely this indication. The EXABLATE MR-guided focused ultrasound system holds FDA Premarket Approval P150038, originally approved in 2016. [1] This device is indicated for use in the unilateral thalamotomy treatment of idiopathic essential tremor patients with medication-refractory tremor, in patients at least 22 years of age. [1] The patient's treated condition — essential tremor — falls squarely within that authorized indication. A device that has received FDA Premarket Approval for the treated indication is, by definition, neither experimental nor investigational when used for that indication. The CO-55 classification is therefore inconsistent with the device's regulatory status. The approved use targets the ventralis intermedius, the area of the brain responsible for the movement-disorder symptoms, which must be identified and accessible for targeted thermal ablation by the device [1] — the established clinical basis for the procedure.

Second, this exact service has been formally studied and is supported in the peer-reviewed scientific literature. The procedure was evaluated in a published randomized trial: Elias WJ, Lipsman N, Ondo WG, et al. A Randomized Trial of Focused Ultrasound Thalamotomy for Essential Tremor. N Engl J Med. 2016. doi:10.1056/NEJMoa1600159 (PubMed PMID 27557301). [2] This is corroborated by a completed, registered clinical investigation of the same intervention. A completed interventional study (ClinicalTrials.gov NCT01827904, completed February 24, 2021) evaluated transcranial ExAblate for essential tremor. [3] That prospective, randomized, double-blind, crossover, multi-site study was designed to test the efficacy and further demonstrate the safety of treatment using the ExAblate Transcranial System in medication-refractory tremor in subjects with essential tremor. [3] A procedure that has been the subject of completed randomized controlled trials and published in a leading peer-reviewed journal is an established, evidence-based treatment, not an investigational one.

Taken together, the FDA marketing authorization for this indication, the published randomized trial evidence, and the recognized specialty-society clinical practice guidance establish that MR-guided focused ultrasound thalamotomy is an accepted treatment for medication-refractory essential tremor. The denial does not engage with this body of authority, and we ask that Cigna's reviewer do so on reconsideration.

We note that a denial on the ground that a service is experimental or investigational for a member's condition is an adverse benefit determination involving medical judgment. As such, it is subject to the full and fair review protections that apply to this plan: a plan and issuer must allow a claimant to review the claim file and to present evidence and testimony as part of the internal claims and appeals process. [4] If Cigna intends to rely on any new or additional rationale or evidence in resolving this appeal, the claimant must be provided that evidence and rationale, free of charge and sufficiently in advance of any final internal adverse determination, with a reasonable opportunity to respond. [4] Should this denial be upheld, this determination is eligible for independent external review by an independent review organization, which conducts a de novo review not bound by the plan's decision. A health insurance issuer offering individual or group coverage must comply with an applicable external review process that includes the consumer protections of the NAIC Uniform External Review Model Act and is binding on the plan. [5] For this patient's Texas-issued coverage, external review is administered through the HHS-Administered Federal External Review process (MAXIMUS Federal Services), with a filing deadline of 120 days after the final internal denial. [6] We reserve the patient's right to pursue that review if necessary.

Because this denial turns on medical judgment, we also request a peer-to-peer review between the treating neurosurgeon and Cigna's reviewing physician of comparable specialty prior to any final determination.

For these reasons, we request that Cigna overturn the CO-55 denial, reprocess claim CIG2026041590233, and pay the claim at the applicable allowed amount. We ask for a written response within 30 days of receipt. If the denial is upheld in whole or in part, we request a complete statement of the specific clinical rationale and the standard relied upon, and we intend to pursue independent external review as described above.

Enclosures:
- Explanation of Benefits dated April 15, 2026
- Operative and office records for the date of service

[PHYSICIAN SIGNATURE]
David R. Okonkwo, MD
NPI: 1379246808
June 27, 2026

References

[1] FDA Premarket Approval P150038 — EXABLATE (MR-guided focused ultrasound system). Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P150038
[2] Elias WJ, Lipsman N, Ondo WG, et al. A Randomized Trial of Focused Ultrasound Thalamotomy for Essential Tremor. N Engl J Med. 2016. doi:10.1056/NEJMoa1600159. (PubMed PMID 27557301). Available at: https://pubmed.ncbi.nlm.nih.gov/27557301/
[3] Completed clinical trial — ExAblate Transcranial MR Guided Focused Ultrasound for the Treatment of Essential Tremors. Available at: https://clinicaltrials.gov/study/NCT01827904
[4] 45 CFR §147.136 - Internal claims and appeals and external review processes (ACA). Available at: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.136
[5] 42 U.S.C. §300gg-19 (ACA §2719) - Appeals process — internal appeals and external review. Available at: https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg-19
[6] External review process - HHS-Administered Federal External Review (MAXIMUS Federal Services) (TX). Available at: https://www.cms.gov/cciio/resources/files/external_appeals