What a reviewer sees, on made-up denials, with the real record underneath.

Item 1 · appeal-packet · example-1 · corrected by Dr Example (fictional reviewer)

chartExcerptSummary: Physical therapy 2026-06-15 to 2026-08-10 (8 weeks, 14 visits); NSAID course 2026-06-15 to 2026-07-30; no red-flag symptoms; persistent radicular pain at week 9.
denial: Example Health Plan (fictional). MRI lumbar spine without contrast, CPT 72148. Denied 2026-09-02. Reason given: "Documentation does not establish six weeks of conservative therapy prior to advanced imaging (policy IMG-104)."
evidence: ["PT progress notes 2026-06-15, 2026-07-08, 2026-08-10 (14 visits documented)","Medication list showing naproxen course 2026-06-15 to 2026-07-30","Office note 2026-08-24: radicular pain persists after conservative care"]
letterDraft: Dear Appeals Reviewer, we request reconsideration of the denial dated 2026-09-02 for lumbar MRI (72148). The record documents eight weeks of physical therapy and a six-week course of naproxen, which exceeds the six weeks of conservative therapy required by your policy. The attached notes show persistent radicular symptoms after that care. We ask that the authorization be approved.
missing: ["Physical therapy discharge summary (requested from the PT clinic; owner: front desk)"]
nextOwner: Biller to attach the PT discharge summary before submission
policyMapped: IMG-104 section 2(b): six weeks of documented conservative therapy including physical therapy or a home exercise program, and a trial of anti-inflammatory medication, before lumbar MRI in the absence of red flags.

Correction written by the reviewer: Quote the policy criterion word for word and give the date of every note you rely on.

Note: Good mapping. The letter should quote IMG-104 2(b) verbatim and date each note; reviewers at this payer check dates first.

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Item 2 · appeal-packet · example-2 · approved by Dr Example (fictional reviewer)

chartExcerptSummary: Office note 2026-09-01: right lower quadrant pain for 9 days, fever 38.4 C, elevated white count 14,200 on 2026-08-31 labs; ultrasound 2026-08-30 non-diagnostic.
denial: Example Health Plan (fictional). CT abdomen and pelvis with contrast, CPT 74177. Denied 2026-09-05. Reason given: "Clinical indication does not meet criteria for advanced imaging (policy IMG-210)."
evidence: ["Office note dated 2026-09-01 (pain, fever 38.4 C)","Laboratory report dated 2026-08-31 (white count 14,200)","Ultrasound report dated 2026-08-30 (non-diagnostic)"]
letterDraft: Dear Appeals Reviewer, we request reconsideration of the denial dated 2026-09-05 for CT abdomen and pelvis (74177). Your policy IMG-210 section 1(a) states: "CT of the abdomen and pelvis is considered medically necessary for suspected appendicitis or intra-abdominal abscess when ultrasound is non-diagnostic or unavailable and the patient has fever or leukocytosis." The ultrasound report dated 2026-08-30 is non-diagnostic; the office note dated 2026-09-01 documents fever of 38.4 C; the laboratory report dated 2026-08-31 documents a white count of 14,200. Each criterion is met. We ask that the authorization be approved.
missing: []
nextOwner: Biller to submit through the payer portal
policyMapped: IMG-210 section 1(a), quoted: "CT of the abdomen and pelvis is considered medically necessary for suspected appendicitis or intra-abdominal abscess when ultrasound is non-diagnostic or unavailable and the patient has fever or leukocytosis."

Prepared under 1 rule in force: item 1: Quote the policy criterion word for word and give the date of every note you rely on.

Note: Quoted and dated. Submit.

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