How to Appeal a UnitedHealthcare Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service Denial
UnitedHealthcare decides coverage for Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service under policy MP.13.19. The most effective appeal shows, point by point, that you meet UnitedHealthcare's own criteria below.
What UnitedHealthcare requires for coverage
UnitedHealthcare considers Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan - Site of Service medically necessary when the following criteria (from MP.13.19) are met:
- Participating in a clinical trial requiring specific imaging protocol or equipment not available in freestanding facility
- Scheduled for MRI/CT within 24 hours of a hospital specialist appointment at the same hospital-based facility
- Known allergy to a contrast agent used for the procedure
- Known chronic disease undergoing active treatment when direct comparison to prior studies requires same imaging protocol or equipment at same hospital-based facility
- Systemic cancer on active treatment when restaging studies require same imaging protocol or equipment used for prior studies at same hospital-based facility
- Pre-procedure imaging done within 24 hours of interventional or surgical procedure that is integral part of planned procedure
- Requires obstetrical observation
- Requires perinatology services
- Under 18 years of age
- Moderate or deep sedation or general anesthesia required and freestanding facility providing such sedation is not available
- Equipment for the size of the individual is not available at freestanding facility
- Open MRI required due to documented diagnosis of claustrophobia and/or severe anxiety not available in freestanding facility
- Imaging in physician office or freestanding imaging center would reasonably be expected to delay care and adversely impact health outcome
Covered procedure codes
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the MP.13.19 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that UnitedHealthcare either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.
Source: UnitedHealthcare medical policy MP.13.19 — view the published policy.