LETTER OF MEDICAL NECESSITY

Date: April 7, 2026

To: Aetna Appeals Department
Re: Claim ID CLM-2026-00001
Patient ID: PAT-10342
Provider ID: PRV-2081
Date of Service: March 18, 2026
CPT Code: 99214
Diagnosis Code: M54.5 (Low back pain, unspecified)

To Whom It May Concern,

I am writing to appeal the denial of the above-referenced claim under reason code CO-50 (Medical Necessity). The service rendered on March 18, 2026 — a Level 4 Evaluation and Management visit (CPT 99214) — was medically necessary for the evaluation and management of the patient's acute low back pain.

The patient presented with a new onset of significant low back pain radiating into the left lower extremity, with associated numbness and reduced range of motion. The provider performed a detailed history including review of prior imaging, a comprehensive musculoskeletal and neurological examination, and moderate-complexity medical decision making including evaluation of differential diagnoses (radiculopathy, disc herniation, and muscular strain) and ordering of follow-up MRI and physical therapy referral.

The level of service documented meets the criteria for CPT 99214 under the 2026 E/M guidelines, as the medical decision making involved moderate number and complexity of problems addressed, moderate amount of data reviewed, and moderate risk of complications or morbidity.

We respectfully request that Aetna reconsider this denial and reprocess the claim for payment.

Sincerely,

Pathfinder Billing and Coding
On behalf of PRV-2081
