MRI was denied even after conservative therapy. How do I appeal?
MRI denials usually say the plan needs documented red flags, neurologic deficits, failed conservative therapy, or x-ray results before advanced imaging. Appeal by matching the plan's imaging criteria with dates, exam findings, treatment tried, and why waiting or repeating conservative care is inappropriate.
What to do, in order
- Step 1
Get the imaging criteria
Ask for the specific policy used by the radiology benefit manager or insurer.
- Step 2
Build the conservative-care timeline
Dates of PT, medications, home exercise, injections, rest, and outcome should be clear.
- Step 3
Highlight objective findings
Neurologic deficits, weakness, abnormal reflexes, trauma, cancer history, fever, or other red flags can change the criteria.
- Step 4
Ask the ordering clinician to write to the criteria
One focused letter is stronger than a general statement that an MRI would be useful.
The deadline that applies
Pre-service imaging appeals are usually decided within 30 days, 72 hours if urgent, and you generally have at least 180 days to file on employer and ACA plans.
Calculate your date →Documents to gather
- MRI denial
- Imaging criteria
- Conservative-care timeline
- Exam findings and red flags
- Ordering clinician statement
Go deeper
Related questions
Does failed physical therapy guarantee an MRI?
No. The plan may require duration, specific findings, or red flags. Document the requirement precisely.
Can a peer-to-peer fix it?
Often, if the missing point is clear and the clinician can quote the record. Still preserve the written appeal deadline.
What if the denial says no records were sent?
Treat it as a records-hold problem first: send the records with proof and ask for reprocessing.
Sources
Share your denial and ask our team about appeal preparation and filing support. $0 upfront. Review the fee and terms before deciding. Apellica is not a law firm and cannot guarantee an outcome.
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