Example practice: Northbridge Orthopedics (fictional)

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)."

Chart excerpt

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.

Payer policy

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."

Evidence

1. Office note dated 2026-09-01 (pain, fever 38.4 C)
2. Laboratory report dated 2026-08-31 (white count 14,200)
3. Ultrasound report dated 2026-08-30 (non-diagnostic)

Appeal letter

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.

Sincerely,

Reviewing clinician: ____________________  Date: ________

Missing items and owners

Not provided.

Rules this packet was prepared under

1. Since item 1 (Dr Example (fictional reviewer)): Quote the policy criterion word for word and give the date of every note you rely on.

Reviewer's correction and note

Note Quoted and dated. Submit.