Sample denial

Date: November 12, 2024

Patient Name: Robert Martinez
DOB: 11/30/1978
Member Number: UHC987654321
Ordering Provider: Dr. Jennifer Walsh, MD
Facility: Regional Imaging Center

Dear Dr. Walsh,

We have reviewed your request for prior authorization for MRI Brain with and without Contrast (CPT 70553) for Mr. Martinez. This request is DENIED.

Reason for Denial: Does Not Meet Prior Authorization Criteria

Clinical Review Findings:
The submitted documentation indicates the patient presents with headaches for 3 weeks. However, the request does not meet UnitedHealthcare's clinical guidelines for advanced neuroimaging because:

1. No red flag symptoms documented (thunderclap headache, fever, neurological deficits)
2. No failed conservative treatment (patient has not tried preventive medications)
3. No baseline CT scan performed
4. Headache pattern consistent with tension-type, not requiring MRI

Our determination is based on:
- UHC Neuroimaging Policy 2024-NEURO-05
- American College of Radiology Appropriateness Criteria
- Choosing Wisely Guidelines for Headache Imaging

Recommended Alternative:
- Headache diary for 4 weeks
- Trial of preventive medication
- CT Head without contrast if symptoms worsen

To appeal, submit additional documentation within 180 days to: UHC Appeals, PO Box 30432, Salt Lake City, UT 84130

Medical Management Department
Reference Number: PA789456123