Your Appeal Letter

[Your Name] [Your Address] [City, State ZIP] [Date]

Appeals Department UnitedHealthcare P.O. Box 30555 Salt Lake City, UT 84130-0555

Re: Appeal of Denial - Claim #UHC-2026-XXXXXX Member: [Your Name] Member ID: [Policy Number] Date of Service: [Treatment Date] Provider: [Doctor Name], MD Procedure: MRI Lumbar Spine (CPT 72148)

Dear Appeals Review Committee:

I am writing to formally appeal the denial of coverage for an MRI of the lumbar spine ordered by my treating physician, [Doctor Name], MD. The denial letter dated [Date] states the procedure is "not medically necessary." This determination is inconsistent with UnitedHealthcare's own medical policy, established clinical guidelines, and Texas state insurance law.

MEDICAL NECESSITY

My treating physician ordered this MRI after eight weeks of conservative treatment, including physical therapy and anti-inflammatory medication, failed to resolve persistent lower back pain with radiculopathy extending to my left leg. I continue to experience numbness and weakness that interferes with daily activities and my ability to work.

Per UnitedHealthcare Medical Policy #2026-0142, MRI of the lumbar spine is considered medically necessary when "conservative treatment has failed after 6 weeks and the patient presents with persistent radiculopathy or progressive neurological deficit." My clinical presentation meets every criterion in your own policy.

CLINICAL GUIDELINES

The American College of Radiology Appropriateness Criteria for Low Back Pain (2024 edition) rates MRI of the lumbar spine without contrast as "usually appropriate" (Rating 8 out of 9) for patients with radiculopathy that has not improved with 6 or more weeks of conservative management.

The American College of Physicians Clinical Practice Guideline (2023) recommends imaging for patients with persistent low back pain accompanied by neurological symptoms when conservative therapy has not produced meaningful improvement within 4-6 weeks.

My clinical history satisfies both guidelines.

STATE AND FEDERAL REQUIREMENTS

Under Texas Insurance Code, Chapter 1305, Section 1305.351, an insurer may not deny a claim for medically necessary services consistent with generally accepted standards of medical practice without providing specific clinical rationale supported by peer-reviewed evidence. The denial letter I received did not cite any clinical evidence contradicting my physician's assessment.

Additionally, under 29 CFR 2560.503-1(h)(2)(iv), the plan is required to provide specific reasons for the adverse determination, including the clinical rationale used. The generic "not medically necessary" language in the denial letter does not meet this standard.

REQUESTED ACTION

I respectfully request that UnitedHealthcare reverse this denial and authorize the MRI of the lumbar spine as ordered by my treating physician. The procedure meets your own medical policy criteria, is supported by published clinical guidelines from the ACR and ACP, and denial without specific clinical rationale violates Texas insurance regulations.

Please process this appeal within the 30-day timeframe required under your plan and Texas law. If this appeal is denied, I intend to pursue an external review through the Texas Department of Insurance.

Enclosed: - Copy of denial letter - Dr. [Name]'s letter of medical necessity - Treatment records documenting 8 weeks of conservative care - Relevant clinical guidelines cited above

Sincerely,

[Your Name] [Phone Number] [Email Address]