Sample Appeal Packet

April 30, 2026

UnitedHealthcare
Appeals & Grievances Department
P.O. Box 30432
Salt Lake City, UT 84130

Re: First-Level Appeal of Pre-Service Denial
Member: Sarah Johnson
Member ID: UHC-CHOICE-PLUS-7891
Claim / Authorization #: UHC-2026-88277
Date of Service Requested: 2026-04-15
Service Denied: MRI Lumbar Spine without contrast (CPT 72148)
Denial Date: 2026-04-10
Plan: UnitedHealthcare Choice Plus (employer-sponsored, ERISA-governed)

Dear Appeals Reviewer:

I am writing to formally appeal UnitedHealthcare's denial dated April 10, 2026, of the MRI of the lumbar spine without contrast (CPT 72148) ordered by my treating physician for the diagnosis of lumbar radiculopathy (ICD-10 M54.16) with associated lumbar disc displacement (ICD-10 M51.26) and radicular pain in the left lower extremity (ICD-10 M54.42). The denial cites "not medically necessary — conservative treatment not exhausted." That conclusion is contradicted by the clinical record and by UnitedHealthcare's own published medical policy. I respectfully request that the denial be overturned and the MRI be authorized.

1. The clinical record satisfies UnitedHealthcare's own coverage criteria

UnitedHealthcare Medical Policy 2024-MRI-LS ("Magnetic Resonance Imaging of the Lumbar Spine"), Section IV(A), states that lumbar MRI is medically necessary when all of the following are documented:

1. Persistent radicular pain or neurologic deficit; and
2. A minimum of six (6) weeks of failed conservative therapy (physical therapy, NSAIDs, or activity modification); and
3. The imaging result is expected to alter management.

Each element is documented in the record submitted with the original prior authorization request:

• Radiculopathy with neurologic deficit. Office note dated 2026-03-28 documents radiating pain from L4 down the left leg, decreased sensation in the L5 dermatome, and a positive straight-leg-raise at 35° on the left. Reflexes are 1+ at the left patella, asymmetric to the right. These findings are textbook L4-L5 radiculopathy.
• Failed conservative therapy. Eight (8) weeks of supervised physical therapy were completed at [PT clinic of record] from 2026-02-03 through 2026-03-28 — exceeding the six-week minimum in policy 2024-MRI-LS. Pain scores remained 7/10 at discharge. NSAIDs (naproxen 500mg BID) were trialed for the same period without sustained relief.
• Imaging will alter management. The treating physician has documented that the next step in care depends on the MRI finding: if a herniated disc with nerve-root impingement is confirmed, the patient is a candidate for an epidural steroid injection or surgical referral; if the MRI is unremarkable, conservative care will continue. Either way, the imaging is decision-determinative.

The denial letter does not address any of these documented elements. It states only that conservative treatment is "not exhausted" — a conclusion that cannot be reconciled with eight weeks of documented PT, documented NSAID failure, and a documented neurologic deficit.

2. The denial conflicts with CMS coverage standards

While this is an employer-sponsored ERISA plan and Medicare coverage rules are not directly binding, CMS National Coverage Determination NCD 220.2 (Magnetic Resonance Imaging) and the consensus criteria used by virtually every commercial payer recognize lumbar MRI as appropriate for documented radiculopathy that has failed at least six weeks of conservative therapy. The American College of Radiology Appropriateness Criteria for "Low Back Pain" rate MRI without contrast as "Usually Appropriate" (rating 7-9) for radiculopathy lasting more than six weeks despite conservative care. UnitedHealthcare's own policy 2024-MRI-LS aligns with these standards. Denying the MRI here is inconsistent with the prevailing standard of care.

3. The denial likely violates ERISA and California law

ERISA § 503 (29 U.S.C. § 1133) and the implementing claims regulation (29 C.F.R. § 2560.503-1(g)(1)) require that an adverse benefit determination provide:

• The specific reason for the denial;
• Reference to the specific plan provisions on which the determination is based; and
• A description of any additional material necessary for the claimant to perfect the claim and an explanation of why such material is necessary.

The April 10, 2026 denial letter recites a generic "not medically necessary" rationale without identifying which element of policy 2024-MRI-LS is unmet, without addressing the documented eight weeks of PT, and without specifying what additional information would change the determination. That is not a § 2560.503-1(g)(1) compliant denial.

For California-sitused members, Cal. Health & Safety Code § 1374.30 (Independent Medical Review) and Cal. Code Regs. tit. 28, § 1300.68 (grievance procedures) provide additional protection: a denial of medically necessary care is reviewable by the Department of Managed Health Care or the Department of Insurance if not overturned at internal appeal. I am preparing concurrent filings with both bodies.

4. What I am requesting

1. Overturn the denial and authorize CPT 72148 (MRI lumbar spine without contrast) as ordered.
2. Provide a full § 2560.503-1(g)(1)-compliant explanation if the denial is upheld, including the specific clinical element of policy 2024-MRI-LS the plan contends is unmet.
3. Identify the reviewing physician's specialty (board certification in orthopedics, neurology, or physiatry is the relevant specialty for a lumbar MRI medical necessity review per ERISA § 503(h)(3)(iii)).
4. Acknowledge receipt of this appeal in writing within 5 business days as required by the plan's summary plan description.

A full clinical packet — office notes, PT discharge summary, NSAID trial documentation, and the original prior authorization request — is attached. I am also enclosing a copy of UnitedHealthcare's published medical policy 2024-MRI-LS for ease of reference.

Under ERISA, I expect a written determination within 30 calendar days of receipt of this appeal (29 C.F.R. § 2560.503-1(i)(2)(iii)). If the appeal is denied, I will pursue external review and the regulatory complaints listed below.

Thank you for the careful re-review this matter requires.

Sincerely,

Sarah Johnson
[Member address on file]

Enclosures:

• Office note 2026-03-28 (treating physician)
• Physical therapy discharge summary 2026-03-28
• NSAID trial documentation 2026-02-03 through 2026-03-28
• UnitedHealthcare denial letter dated 2026-04-10
• UnitedHealthcare Medical Policy 2024-MRI-LS

cc:

• California Department of Insurance — Consumer Services Division
• California Department of Managed Health Care — Help Center
• U.S. Department of Labor, Employee Benefits Security Administration
• UnitedHealthcare Office of the Plan Medical Director
• Treating physician of record

April 30, 2026

California Department of Insurance
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013

Re: Consumer Complaint — Medically Necessary Denial — UnitedHealthcare Choice Plus
Complainant: Sarah Johnson
Insurer: UnitedHealthcare Insurance Company
Plan: UHC Choice Plus (employer-sponsored)
Claim/Auth #: UHC-2026-88277
Service Denied: MRI Lumbar Spine without contrast (CPT 72148)
Denial Date: 2026-04-10

Dear Consumer Services Division:

I am filing this complaint concurrently with my first-level internal appeal to UnitedHealthcare. I am asking the Department to:

1. Open a complaint file documenting this denial.
2. Review whether the April 10, 2026 denial letter complies with ERISA § 503 and 29 C.F.R. § 2560.503-1(g)(1) — the denial contains a generic "not medically necessary" rationale without identifying which element of UnitedHealthcare's own medical policy 2024-MRI-LS is unmet.
3. Stand by to receive my Independent Medical Review (IMR) request under Cal. Health & Safety Code § 1374.30 if UnitedHealthcare upholds the denial at internal appeal.

Background

My treating physician ordered an MRI of the lumbar spine without contrast (CPT 72148) for documented lumbar radiculopathy (ICD-10 M54.16) with an L5-dermatome neurologic deficit, after I completed eight (8) weeks of supervised physical therapy and a documented NSAID trial without sustained relief. UnitedHealthcare's own medical policy (2024-MRI-LS) requires only six (6) weeks of conservative therapy plus documented radicular symptoms — both criteria are met and exceeded.

UnitedHealthcare denied the request on April 10, 2026, citing only "not medically necessary — conservative treatment not exhausted." The denial letter does not:

• Identify which clinical element of policy 2024-MRI-LS is unmet;
• Address the documented eight weeks of physical therapy;
• State what additional information would change the determination;
• Disclose the reviewing physician's specialty.

These are the disclosures required by 29 C.F.R. § 2560.503-1(g)(1). This complaint asks the Department to confirm whether the denial as written meets that standard.

Why this matters beyond my case

A denial that recites a generic phrase without addressing the documented record — and without identifying the policy criterion at issue — is a process failure that affects every California member of this plan. If the Department finds the denial letter substantively non-compliant, the remedy I am asking for (a corrected, fully-explained determination) is a remedy that benefits the plan's other members as well.

What I have attached

• A copy of the April 10, 2026 denial letter from UnitedHealthcare.
• A copy of my first-level internal appeal dated April 30, 2026 (filed concurrently).
• The clinical record: office note, PT discharge summary, NSAID trial documentation.
• A copy of UnitedHealthcare's published medical policy 2024-MRI-LS.

I am happy to provide any additional information the Department requests. The fastest way to reach me is by email at the address on file with the Department.

Thank you for your time and for the work the Consumer Services Division does to keep insurers honest with California families.

Sincerely,

Sarah Johnson
[Member address on file]

cc: UnitedHealthcare Appeals & Grievances Department