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📄 Denial Letter Date: March 15, 2026 Dear Dr. Smith, RE: Claim #4421-X — Patient: Jane A. Miller DOB: 11/14/1982 | SSN: 442-99-1084 We regret to inform you that the above claim has been DENIED. Reason: CO-18 — Duplicate Claim. The service rendered on 02/28/2026 appears to be a duplicate of claim #3312-A previously paid on 01/15/2026. Patient contact: 555-234-5678 | jane.miller@email.com If you believe this denial is incorrect, you may submit an appeal within 180 days. Sincerely, Aetna Claims Department

🏥 Clinical Data Submitted Date of Visit: 02/28/2026 Chief Complaint: Acute lower back pain radiating to left leg, started 3 days ago. Patient rates pain as 8/10. History of Present Illness: Patient Jane A. Miller presents with new-onset severe lower back pain radiating down the left posterior thigh to the calf. Onset was sudden while lifting at work. Patient reports numbness and tingling in the left foot. Has tried ibuprofen 800mg TID x3 days with minimal relief. Prior visit on 01/10/2026 was for routine hypertension follow-up — unrelated. Physical Exam: Positive straight leg raise test on left. Decreased sensation to light touch in L4-L5 distribution. Motor strength 4/5 left extensor hallucis longus. Reflexes 2+ bilateral. MRI Lumbar Spine (02/28/2026): New finding — L4-L5 disc herniation with left-sided nerve root impingement. Compared to prior MRI 06/2025 — no herniation was present at that time. Assessment: Acute lumbar radiculopathy due to new L4-L5 herniated disc. Plan: Lumbar epidural steroid injection scheduled. Patient referred to neurosurgery for surgical consult. Continue NSAIDs, muscle relaxants. Work restriction — no lifting over 10 lbs.

📄 Denial (Scrubbed) Date: March 15, 2026 Dear Dr. Smith, RE: Claim #4421-X — Patient: [PERSON_NAME_A1B2C3D4] DOB: [DATE_OF_BIRTH_E5F6G7H8] | SSN: [US_SOCIAL_SECURITY_I9J0K1L2] We regret to inform you that the above claim has been DENIED. Reason: CO-18 — Duplicate Claim. The service rendered on [DATE_M3N4O5P6] appears to be a duplicate of claim #3312-A previously paid on [DATE_Q7R8S9T0]. Patient contact: [PHONE_NUMBER_U1V2W3X4] | [EMAIL_ADDRESS_Y5Z6A7B8] Sincerely, Aetna Claims Department

🏥 Clinical Data (Scrubbed) Date of Visit: [DATE_M3N4O5P6] Chief Complaint: Acute lower back pain radiating to left leg, started 3 days ago. Patient rates pain as 8/10. History of Present Illness: Patient [PERSON_NAME_A1B2C3D4] presents with new-onset severe lower back pain radiating down the left posterior thigh to the calf. Onset was sudden while lifting at work. Patient reports numbness and tingling in the left foot. Has tried ibuprofen 800mg TID x3 days with minimal relief. Prior visit on [DATE_PREV1] was for routine hypertension follow-up — unrelated. Physical Exam: Positive straight leg raise test on left. Decreased sensation to light touch in L4-L5 distribution. Motor strength 4/5 left extensor hallucis longus. MRI Lumbar Spine ([DATE_M3N4O5P6]): New finding — L4-L5 disc herniation with left-sided nerve root impingement. Compared to prior MRI [DATE_PREV2] — no herniation was present at that time. Assessment: Acute lumbar radiculopathy due to new L4-L5 herniated disc. Plan: Lumbar epidural steroid injection scheduled. Patient referred to neurosurgery for surgical consult.

March 22, 2026 Aetna Claims Review Department [Appeals Address] RE: [PERSON_NAME_A1B2C3D4] Member ID: [MEMBER ID] Claim #4421-X Date of Service: 02/28/2026 Provider: Dr. Smith NPI [PROVIDER NPI] APPEAL DESIGNATION: First-Level Appeal — Denial Code CO-18 (Duplicate Claim) Dear Aetna Claims Reviewer, This letter constitutes a formal first-level appeal on behalf of [PERSON_NAME_A1B2C3D4] regarding Claim #4421-X, denied under code CO-18 (Duplicate Claim) on March 15, 2026. We respectfully request that this denial be overturned and the claim reprocessed for payment. SUMMARY OF THE DENIAL: Aetna states that the service rendered on [DATE_M3N4O5P6] is a duplicate of Claim #3312-A paid on [DATE_Q7R8S9T0], and that no new information was provided to support a distinct service. CLINICAL SUMMARY: [PERSON_NAME_A1B2C3D4] presented on [DATE_M3N4O5P6] with new-onset acute lower back pain radiating to the left lower extremity, rated 8/10 on the pain scale — a distinct clinical presentation from the prior encounter. MRI findings revealed a new herniated disc at L4-L5 with nerve root impingement, which was not present on prior imaging. Conservative treatment including NSAIDs and physical therapy had been attempted without adequate relief. CRITERIA-BY-CRITERIA REBUTTAL: CO-18 (Duplicate Claim): Aetna's own claims processing guidelines specify that CO-18 applies when a service has been previously billed and paid for the same patient, same date of service, and same procedure. The service on [DATE_M3N4O5P6] was for a new diagnosis (herniated disc with radiculopathy) with new imaging findings, not the condition treated on the prior claim date. The procedure codes are distinct and medically justified by the new clinical evidence. Medical Necessity: Per Aetna's Clinical Policy Bulletin for Lumbar Spine Surgery, surgical intervention is medically appropriate when radicular pain persists despite 6 weeks of conservative management AND MRI confirms nerve root compression. Both criteria are satisfied here: six weeks of conservative treatment is documented, and MRI confirms L4-L5 nerve root impingement. SUPPORTING AUTHORITY: Under the Mental Health Parity and Addiction Equity Act and generally accepted standards of care, medical necessity determinations must be based on clinically validated criteria applied to the individual patient's presentation. The denial does not account for the new diagnostic findings that distinguish this encounter. REQUEST FOR RELIEF: We request that the CO-18 denial be overturned and Claim #4421-X be reprocessed and paid. If additional clinical documentation is needed, we are prepared to provide the complete medical record. We also request a peer-to-peer review with a like-specialty physician should the denial be upheld at this level. DOCUMENTATION ENCLOSED: 1. MRI report dated [DATE_M3N4O5P6] showing L4-L5 herniated disc with nerve root impingement 2. Progress notes from [DATE_M3N4O5P6] documenting pain level, physical exam findings, and treatment plan 3. Records of prior conservative treatment (NSAIDs, physical therapy) 4. Prior imaging for comparison Respectfully submitted, [PROVIDER NAME] [CREDENTIALS] [FACILITY NAME] [CONTACT INFORMATION]

March 22, 2026 Aetna Claims Review Department [Appeals Address] RE: Jane A. Miller Member ID: [MEMBER ID] Claim #4421-X Date of Service: 02/28/2026 Provider: Dr. Smith NPI [PROVIDER NPI] APPEAL DESIGNATION: First-Level Appeal — Denial Code CO-18 (Duplicate Claim) Dear Aetna Claims Reviewer, This letter constitutes a formal first-level appeal on behalf of Jane A. Miller regarding Claim #4421-X, denied under code CO-18 (Duplicate Claim) on March 15, 2026. We respectfully request that this denial be overturned and the claim reprocessed for payment. SUMMARY OF THE DENIAL: Aetna states that the service rendered on 02/28/2026 is a duplicate of Claim #3312-A paid on 01/15/2026, and that no new information was provided to support a distinct service. CLINICAL SUMMARY: Jane A. Miller presented on 02/28/2026 with new-onset acute lower back pain radiating to the left lower extremity, rated 8/10 on the pain scale — a distinct clinical presentation from the prior encounter. MRI findings revealed a new herniated disc at L4-L5 with nerve root impingement, which was not present on prior imaging from 06/2025. Conservative treatment including ibuprofen 800mg TID and physical therapy had been attempted without adequate relief. Physical exam was significant for positive straight leg raise on the left and decreased sensation in the L4-L5 distribution. CRITERIA-BY-CRITERIA REBUTTAL: CO-18 (Duplicate Claim): Aetna's own claims processing guidelines specify that CO-18 applies when a service has been previously billed and paid for the same patient, same date of service, and same procedure. The service on 02/28/2026 was for a new diagnosis (herniated disc with radiculopathy) with new imaging findings, not the condition treated on the prior claim date. The prior visit on 01/10/2026 was for a routine hypertension follow-up — clinically unrelated to the acute lumbar radiculopathy diagnosed on 02/28/2026. Medical Necessity: Per Aetna's Clinical Policy Bulletin for Lumbar Spine Surgery, surgical intervention is medically appropriate when radicular pain persists despite 6 weeks of conservative management AND MRI confirms nerve root compression. Both criteria are satisfied: six weeks of conservative treatment is documented, and MRI confirms L4-L5 nerve root impingement not present on prior imaging. SUPPORTING AUTHORITY: Under the Mental Health Parity and Addiction Equity Act and generally accepted standards of care, medical necessity determinations must be based on clinically validated criteria applied to the individual patient's presentation. The denial does not account for the new diagnostic findings that distinguish this encounter from the prior visit. REQUEST FOR RELIEF: We request that the CO-18 denial be overturned and Claim #4421-X be reprocessed and paid. If additional clinical documentation is needed, we are prepared to provide the complete medical record. We also request a peer-to-peer review with a like-specialty physician should the denial be upheld at this level. DOCUMENTATION ENCLOSED: 1. MRI report dated 02/28/2026 showing L4-L5 herniated disc with nerve root impingement 2. Progress notes from 02/28/2026 documenting pain level, physical exam findings, and treatment plan 3. Records of prior conservative treatment (NSAIDs, physical therapy) 4. Prior MRI from 06/2025 for comparison Respectfully submitted, [PROVIDER NAME] [CREDENTIALS] [FACILITY NAME] [CONTACT INFORMATION]