MRI Denied by Insurance

What to do first

Ask the plan for the written denial and the exact reason. Find out whether it denied approval before the scan or denied the claim after the scan. Ask whether the issue is missing records, the medical-need criteria, the type of scan, or the imaging location.

Ask the ordering clinician’s office to review the notice and send records that address the reason given. If you appeal, use the plan’s form or instructions and follow its deadline. Ask the plan and your clinician about an urgent review if waiting could affect your care.

Keep the denial, records you send, and notes from calls. If the plan upholds the denial, check the notice for any next review step. If the scan already happened, ask the billing office about the account while coverage is being reviewed.

References: CMS: Action plan for a denied insurance claim · HealthCare.gov: Internal appeals

Identify exactly what was denied

Confirm the body area, type of MRI, contrast if relevant, ordering clinician, imaging facility, and requested date. A denied authorization before a scan differs from a claim denial afterward. Ask which policy and criteria the reviewer applied.

Separate missing records from unmet criteria

If the plan did not receive the order, exam findings, prior test results, or treatment history, ask the clinician’s office to supply the relevant material. If the plan reviewed those records and disagrees, request the clinical rationale. Do not assume every scan requires the same number of weeks of treatment or the same preliminary test.

Check authorization and site of service

Ask whether approval was required and whether it covered the actual facility and dates. A plan may treat a hospital imaging department differently from a freestanding center. Ask about a covered alternative only if your clinician considers it appropriate; do not change a medically necessary plan of care based solely on this guide.

Build the appeal with the ordering clinician

Have the clinician address the denied criterion and explain why the scan is needed in your circumstances. Include the order, relevant notes, prior results, and authorization history. A published insurer imaging policy is an example of criteria, not proof of what your specific benefit plan covers.

Protect timing and any existing bill

Ask whether a clinician discussion or corrected authorization request counts as your appeal. Follow the formal notice if it does not. For urgent clinical needs, ask about expedited review. If the scan already happened, request a billing hold and confirm who the plan assigns responsibility to before treating the entire charge as yours.

Which plan rules apply?

For commercial coverage, check the policy and state-specific instructions. A self-funded employer plan can use different oversight and appeal rules even when an insurer administers claims. Medicare and Medicaid use program-specific notices and review routes. Confirm the applicable deadline, whether a correction counts as an appeal, and where to escalate; do not substitute a deadline from a different plan.