Sample: a Medicare Advantage MRI denial

Ruth's plan denied a lumbar MRI as not medically necessary. This is the full $59 report, with the appeal ready to approve and send.

Denied for medical necessity. You have 53 days to appeal (until January 4, 2027). We found 4 appeal points for your letter.

4appeal points$1,840denied amount at stake

Plan: Medicare Advantage plan (Lakeshore Senior Advantage (HMO))
Denied: MRI of the lumbar spine without contrast
Reason given: Not medically necessary. Records do not show 6 weeks of conservative therapy before advanced imaging.
Notice date: October 31, 2026
Amount: $1,840.00
Deadline: January 4, 2027 (from your notice)

Check these against your document. This is a sample with a fictional patient.

What to do, in order

Put January 4, 2027 on your calendar. That's your filing deadline.
Send the letter-of-medical-necessity request to your doctor today.
Ask the plan for your claim file and the exact criteria it used.
Send the appeal with the doctor's letter and records, with proof of delivery.
Ask the provider to hold the bill while the appeal is open.
If the plan says no again, go to independent review: it's free and the plan must follow the decision.

Appeal points

Likely errors first. Every finding comes from a written rule you can check.

Your right

File by January 4, 2027 (53 days left)

Next step: Reconsideration (first appeal) with the plan. This deadline comes from your notice. Send it so it arrives well before then, and keep proof of delivery.

Basis: Window stated on your notice

Your right

Get your claim file and the criteria used, free

You can ask for every document the plan relied on, including the clinical guideline and the reviewer's notes. These show exactly what your doctor's letter needs to answer.

What to ask for: Send me, free of charge, copies of all documents, records and other information relevant to my claim, including any internal rule, guideline or criteria relied on.

Basis: 42 CFR §422.586 (right to present evidence; access to case file)

Your right

Medicare Advantage: a second, independent look is automatic

If your plan denies the reconsideration in whole or part, it must send your case to an Independent Review Entity on its own.

Basis: 42 CFR §422.590–592

Worth questioning$1,840.00

Medical-necessity denial: answer it with your doctor's evidence

These denials are decided on paperwork, so better paperwork can change them. Answer by showing the care meets the plan's own criteria: a letter of medical necessity from your doctor, the relevant chart notes, and what you already tried that didn't work. Ask the plan for the exact clinical criteria it used, and for a reviewer in the same specialty.

What to ask for: Overturn the medical-necessity denial. Please provide, free of charge, the clinical criteria, guidelines and reviewer credentials relied on, and have the appeal reviewed by a physician in the same or a similar specialty who was not involved in the initial decision.

Basis: 29 CFR §2560.503-1(h)(2)(iii) and (h)(3)(iii)

Next step

Ask the provider to hold the bill while you appeal

Call the provider's billing office, tell them you've appealed, and ask them to put the account on hold so it doesn't go to collections during the review.

Review, approve and send

Read the appeal and change anything you like. When you approve it, we fax it with your denial notice to the plan's appeals fax and send a certified-mail copy. Receipts go to your email. Deadline: January 4, 2027.

The appeal letter 4 [bracketed] blanks left to fill in or delete

Ruth Delgado
[Your mailing address]
[Your phone or email]

November 12, 2026

Lakeshore Senior Advantage (HMO)
Attn: Appeals Department
Lakeshore Senior Advantage, Attn: Appeals & Grievances, PO Box 6120, Milwaukee, WI 53201. Fax (555) 010-8830

Re: Request for reconsideration (first appeal) with the plan
Member: Ruth Delgado
Member ID: LSA448190227
Claim or reference number: OD-2026-1147395
Service: MRI of the lumbar spine without contrast (72148)
Date of service: Not yet provided (pre-service request)
Date of denial notice: October 31, 2026
Provider: Dr. Samuel Okafor, Lakeshore Orthopedics

To the appeals reviewer:

I am appealing the decision to deny coverage for MRI of the lumbar spine without contrast ($1,840.00). The notice says the claim was denied as not medically necessary: "Not medically necessary. Records do not show 6 weeks of conservative therapy before advanced imaging.". I believe this decision is wrong, for the reasons below.

[In two or three sentences, describe your condition, what your doctor recommended and why, and what happens without this care. Plain words are best.]

My requests:

1. Send me, free of charge, copies of all documents, records and other information relevant to my claim, including any internal rule, guideline or criteria relied on. (42 CFR §422.586 (right to present evidence; access to case file))
  2. Overturn the medical-necessity denial. Please provide, free of charge, the clinical criteria, guidelines and reviewer credentials relied on, and have the appeal reviewed by a physician in the same or a similar specialty who was not involved in the initial decision. (29 CFR §2560.503-1(h)(2)(iii) and (h)(3)(iii))

Enclosed:
  - A copy of the denial notice
  - A letter of medical necessity from my treating provider
  - Relevant medical records and test results
  - [Any other supporting documents, e.g. studies or prior treatments tried]

Please send me your written decision within the time required for a Medicare Advantage plan. Plans decide in 30 days for care you haven't had yet, 60 days for payment, or 72 hours if expedited.

Please also confirm receipt of this appeal in writing.

Sincerely,

Ruth Delgado

Where it goes

Plan's appeals faxRead from your notice.

Plan's appeals mailing address (for the certified copy)

Name

Street address

Apt, suite, PO box (optional)

City

State

ZIP

You

Name

Street address

Apt, suite, PO box (optional)

City

State

ZIP

Email for receipts and deadline reminders

I've read this appeal, it's accurate, and I approve sending it in my name. I understand Owed prepares and sends documents and is not my lawyer.

Your documents

Fill in anything in [brackets]. The appeal above is the one we send; these are copies for your records and for your doctor.

Appeal letter

To: Lakeshore Senior Advantage (HMO), appeals address on your notice. Send so it arrives before January 4, 2027. Use certified mail, fax with confirmation, or the plan's portal.

Ruth Delgado
[Your mailing address]
[Your phone or email]

November 12, 2026

Lakeshore Senior Advantage (HMO)
Attn: Appeals Department
Lakeshore Senior Advantage, Attn: Appeals & Grievances, PO Box 6120, Milwaukee, WI 53201. Fax (555) 010-8830

Re: Request for reconsideration (first appeal) with the plan
Member: Ruth Delgado
Member ID: LSA448190227
Claim or reference number: OD-2026-1147395
Service: MRI of the lumbar spine without contrast (72148)
Date of service: Not yet provided (pre-service request)
Date of denial notice: October 31, 2026
Provider: Dr. Samuel Okafor, Lakeshore Orthopedics

To the appeals reviewer:

I am appealing the decision to deny coverage for MRI of the lumbar spine without contrast ($1,840.00). The notice says the claim was denied as not medically necessary: "Not medically necessary. Records do not show 6 weeks of conservative therapy before advanced imaging.". I believe this decision is wrong, for the reasons below.

[In two or three sentences, describe your condition, what your doctor recommended and why, and what happens without this care. Plain words are best.]

My requests:

  1. Send me, free of charge, copies of all documents, records and other information relevant to my claim, including any internal rule, guideline or criteria relied on. (42 CFR §422.586 (right to present evidence; access to case file))
  2. Overturn the medical-necessity denial. Please provide, free of charge, the clinical criteria, guidelines and reviewer credentials relied on, and have the appeal reviewed by a physician in the same or a similar specialty who was not involved in the initial decision. (29 CFR §2560.503-1(h)(2)(iii) and (h)(3)(iii))

Enclosed:
  - A copy of the denial notice
  - A letter of medical necessity from my treating provider
  - Relevant medical records and test results
  - [Any other supporting documents, e.g. studies or prior treatments tried]

Please send me your written decision within the time required for a Medicare Advantage plan. Plans decide in 30 days for care you haven't had yet, 60 days for payment, or 72 hours if expedited.

Please also confirm receipt of this appeal in writing.

Sincerely,


Ruth Delgado

Letter-of-medical-necessity request for your doctor

To: Dr. Samuel Okafor, Lakeshore Orthopedics: give it to the office or send through the patient portal. Send today. Doctors' offices often need a week or two, and this letter decides most appeals.

Dear Dr. Samuel Okafor, Lakeshore Orthopedics,

My Medicare Advantage plan (Lakeshore Senior Advantage (HMO)) denied coverage for MRI of the lumbar spine without contrast (72148) as not medically necessary. I'm appealing, and my deadline is January 4, 2027. Could you write a letter of medical necessity for my appeal? It would help most if it covers:

  1. My diagnosis (with ICD-10 codes) and how long I've had it
  2. Why this specific service is needed now, and what is likely to happen without it
  3. Treatments already tried, with dates, and why they failed or aren't appropriate
  4. How my case meets the plan's coverage criteria (I've asked the plan for them and will forward them when they arrive)
  5. Any guidelines or peer-reviewed studies supporting this treatment for my condition

Please put it on your letterhead, sign it, and send it to me (or directly to the plan's appeals department, with my claim number on each page).

Claim/reference number: OD-2026-1147395
Member ID: LSA448190227

Thank you for your help.

Ruth Delgado
[Date of birth]
[Phone]

Deadline checklist

To: For you. Print it or keep it on your phone.. Use it to track each step until you have a decision.

Appeal checklist: Ruth Delgado, claim OD-2026-1147395

Plan type: Medicare Advantage plan (Lakeshore Senior Advantage (HMO))
Next step: Reconsideration (first appeal) with the plan
Deadline: January 4, 2027 (53 days from November 12, 2026). Source: Window stated on your notice.
Always use the date on your notice if it is earlier than ours.

[ ] Today: ask the provider's billing office to hold the bill while you appeal
[ ] Today: send the letter-of-medical-necessity request to your doctor
[ ] Today: ask the plan (phone or portal) for your full claim file and the criteria used
[ ] By December 21, 2026: collect the doctor's letter and records
[ ] By December 28, 2026: send the appeal (certified mail, fax with confirmation, or portal) and keep copies of everything
[ ] 5 business days after sending: call to confirm the plan received it, and note the reference number
[ ] Decision expected: Plans decide in 30 days for care you haven't had yet, 60 days for payment, or 72 hours if expedited.
[ ] If denied: the plan must forward your case to the Independent Review Entity automatically. Watch for their letter.

Call log (date, who, what they said, reference number):
  -
  -
  -

Free help: your state's Consumer Assistance Program (healthcare.gov/marketplace/c/external-review), or for Medicare, your State Health Insurance Assistance Program (shiphelp.org).

Ready to check yours?

The scan is free. You only pay $59 if you want the full appeal, sent for you.

Check my denial