Example practice: Northbridge Orthopedics (fictional)

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)."

Chart excerpt

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.

Payer policy

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.

Evidence

1. PT progress notes 2026-06-15, 2026-07-08, 2026-08-10 (14 visits documented)
2. Medication list showing naproxen course 2026-06-15 to 2026-07-30
3. Office note 2026-08-24: radicular pain persists after conservative care

Appeal letter

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.

Sincerely,

Reviewing clinician: ____________________  Date: ________

Missing items and owners

• Physical therapy discharge summary (requested from the PT clinic; owner: front desk)

Owner Biller to attach the PT discharge summary before submission

Rules this packet was prepared under

No rules were in force when this packet was prepared.

Reviewer's correction and note

Correction 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.