Request for clinical reconsideration

We appeal the denial of the above claim for services rendered by Summit Orthopedic Center. The denial states: Medical necessity documentation was not included with the original claim.

Procedure 27447 was medically appropriate for the patient's documented condition, diagnosis M17.11. The enclosed clinical record supports the medical necessity and accurate billing of this service.

Please reconsider the denial and reprocess claim DEMO-CLM-1001 for the billed amount of $48,750.00 in accordance with the member's benefits.

Please issue a written determination before the appeal deadline of Aug 4, 2026. If additional information is required, contact our appeals team so that it can be supplied without delay.