Denial OS · Appeal generator
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Live toolAnthem Blue Cross of California · Provider Disputes
Re: Formal Appeal of CO-97 Denial · Claim #SP-47291 · DOS 04/12/2026
This letter formally appeals the denial of CPT 97110 + 97140, denied under CARC CO-97. Modifier XS was attached on the original claim line (Exhibit B); services were performed on distinct anatomic sites per CMS NCCI Policy Manual Ch 11 and MLN Matters MM10385.
Per Anthem Blue Cross of California's Transparency in Coverage machine-readable file effective 2026-04-01, the contracted in-network rate for CPT 97110 in California is $94.20 per unit, and for 97140 is $78.90 per unit. Source: anthem_ca_2026-04-01.json.gz · billing_class professional · negotiated_type negotiated. Total contractually owed: $173.10.
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Letter preview · #SP-47291
2840 Riverside Blvd · Sacramento, CA 95818
NPI 1234567893 · TIN 88-2104XXX
Re: Patient #4071 · DOS 2026-04-12
Claim #SP-47291
Anthem Blue Cross of California
Provider Disputes — PO Box 60007
Los Angeles, CA 90060-0007
Re: Formal Appeal of CO-97 Denial · CPT 97110 + 97140
To Whom It May Concern,
This letter formally appeals the denial of claim #SP-47291 for member [redacted], denied under CARC code CO-97 (“The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated”) for date of service April 12, 2026.
The denied codes — CPT 97110 (therapeutic exercise, 15 min) and CPT 97140 (manual therapy, 15 min) — were performed in distinct, non-overlapping 15-minute encounters on separate anatomic sites, fully documented in the encounter note attached as Exhibit A. The services qualify for modifier 59 / XS under CMS NCCI Policy Manual Chapter 11 and MLN Matters MM10385, which permits the X{EPSU} modifier set when distinct anatomic sites are documented. The XS modifier was attached to CPT 97140 on the original claim line (Exhibit B).
Per Anthem Blue Cross of California's Transparency in Coverage machine-readable file effective April 1, 2026, the contracted in-network rate for CPT 97110 in the State of California is $94.20 per unit, and the contracted rate for CPT 97140 is $78.90 per unit (source: anthem_blue_cross_of_california_2026-04-01_in-network-rates.json.gz, billing code 97110, billing class professional, negotiated_type negotiated, expiration_date 9999-12-31, retrieved by ReimburseOS data engine 2026-04-15). The total contractually owed amount on this claim is therefore $173.10.
Per Anthem CA Provider Manual §7.4 and the Anthem CA / California Department of Managed Health Care Provider Dispute Resolution Process, we request the denial be overturned and the claim reprocessed at the contracted rate above within the regulatory 45-business-day window.
Documentation enclosed:
Exhibit A — Treatment encounter note · 04-12-2026
Exhibit B — Original CMS-1500 with XS modifier
Exhibit C — Anthem CA TiC MRF excerpt (97110, 97140)
Exhibit D — CMS NCCI Policy Manual Ch 11.B
Respectfully,
Sunrise Demo Physical Therapy — Billing Department
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