May 20, 2026 Claims Appeals Department [Insurance Company Name] [Payer Address Line 1] [City, State ZIP] RE: Formal Appeal — Claim ID CLM-1002 Patient: Robert Chen Date of Service: 2025-02-28 Procedure Code: 27447 Billed Amount: $8,420.50 Denial Reason: Prior authorization not obtained Appeal Reference: CLM-1002-20260520 To Whom It May Concern: We are writing on behalf of Feezza Inc. and our client facility to formally appeal the denial of the above-referenced claim. This appeal is submitted in accordance with your plan's internal appeals process and applicable federal and state regulations governing claims disputes. The services provided on 2025-02-28 were rendered under urgent clinical circumstances that did not permit the standard prior authorization process to be completed before treatment was initiated. Under federal and state prompt pay regulations, including applicable provisions of the ACA, insurers are required to cover urgent and emergent services regardless of prior authorization status. Furthermore, a retroactive review of the clinical documentation confirms that the services would have met authorization criteria had the request been submitted in advance. We request that this claim be approved on the basis of clinical urgency and the patient's benefit entitlement, and ask that you conduct a retrospective authorization review consistent with your plan's own policy provisions. We respectfully request that this claim be reconsidered and reprocessed for payment in full within the timeframe required by applicable prompt pay regulations. Please confirm receipt of this appeal in writing and advise if any additional documentation is required to complete your review. Sincerely, Hospital Billing & Revenue Cycle Team Feezza Inc. | Wintora wintora.ai · legal@feezza.com Appeal Reference: CLM-1002-20260520 --- DISCLAIMER: This appeal letter was generated with the assistance of Wintora software by Feezza Inc. The clinical and administrative assertions contained herein are based on information provided by the submitting provider and have been auto-generated using established claims appeal frameworks. This letter should be reviewed by an authorized representative of the provider prior to submission. Feezza Inc. makes no warranty regarding the outcome of any appeal.