May 20, 2026 Claims Appeals Department [Insurance Company Name] [Payer Address Line 1] [City, State ZIP] RE: Formal Appeal — Claim ID CLM-1007 Patient: Lisa Anderson Date of Service: 2025-02-10 Procedure Code: 97110 Billed Amount: $1,560.00 Denial Reason: Service not covered under plan Appeal Reference: CLM-1007-20260520 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. We respectfully dispute the determination that this service is not covered. A review of the patient's benefit summary indicates that procedure code 97110 falls within the covered services category for this member's plan type. If your determination is based on a specific exclusion clause, we request the exact policy language and exclusion reference number. If the denial is related to a coverage tier or network issue, we request a detailed explanation of the specific benefit limitation applied, as this information is necessary to evaluate the accuracy of the denial. 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-1007-20260520 --- 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.