Maria Gonzalez
Date of Birth: April 15, 1978
Member ID: U123456789
Date: June 15, 2026
Cigna Health and Life Insurance Company – Appeals Unit
P.O. Box 188004
Chattanooga, TN 37422
RE: APPEAL OF DENIAL – CPT 95251 (Ambulatory Glucose Profile) – Claim Denied CO-50 – Maria Gonzalez
To Whom It May Concern:
I am writing to formally appeal the denial of coverage for CPT 95251 (Ambulatory Glucose Profile/CGM Interpretation), denied on June 1, 2026 under reason code CO-50 (not medically necessary). I respectfully request that Cigna reconsider this determination and approve coverage for this service.
This service is medically necessary for the management of my Type 2 Diabetes with Hyperglycemia (ICD-10 E11.65). CPT 95251 represents the professional interpretation of continuous glucose monitor data, a service whose medical necessity is well-established by clinical guidelines including ADA Standards of Care 2026. Denial under CO-50 is inconsistent with these standards and my treating physician's clinical judgment.
I respectfully request that Cigna reverse the denial of CPT 95251 and approve coverage as medically necessary. Please provide a written determination within the timeframe required by applicable law and your Evidence of Coverage.
Thank you for your prompt attention to this matter. I am available to provide additional information as needed.
Sincerely,
Maria Gonzalez
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