How to Get Insurance to Cover an MRI (and Appeal a Denial)

Written by Aptiva Health Editorial Team · Medically reviewed by Thomas Huhn, MD · Reviewed by Crystal Brake, RCM Director · Editorial & review standards · How we research

An MRI (magnetic resonance imaging) gives a detailed picture of soft tissue, such as discs, nerves, ligaments and cartilage. It is often ordered for back and neck pain, knee and shoulder injuries, and concussion symptoms.

MRIs are also one of the services health plans most often review before paying. This guide explains what plans usually look for, how to get the request right the first time, and what to do if the MRI is denied. It is part of the Coverage & Appeals Center.

Why MRIs get denied

MRI denials usually fall into one of these groups:

• Not medically necessary. The records didn’t show you meet the plan’s criteria. See not medically necessary denials.
• No prior authorization. Approval was required and not on file. See missing prior authorization.
• Too soon. The plan wants other treatment tried first.
• Wrong test or body part. The approved code doesn’t match the MRI that was done (for example, with vs. without contrast).

What plans usually look for

Each plan has its own written policy for imaging. Many plans also use a separate company to review imaging requests.

The criteria below are common examples, not rules for your plan. Ask your plan for its exact policy.

• Symptoms and how long you have had them. Many policies want symptoms to last several weeks before imaging for back pain without warning signs.
• A documented exam. Findings such as strength, reflexes, numbness or joint instability.
• Conservative care tried first. For example, physical therapy, medicine or activity changes for a set number of weeks.
• “Red flag” signs. Signs of a serious problem, such as new weakness, may allow an MRI sooner.
• X-rays first for some joint problems.
• A clear plan for the result. How the MRI will change treatment, such as planning an injection or surgery.

Guidelines your clinician may cite

Professional guidelines help show an MRI is appropriate. The American College of Radiology publishes the ACR Appropriateness Criteria (ACR Appropriateness Criteria). Orthopedic and spine societies also publish guidance. Your clinician can cite the guideline that fits your case.

What to ask your clinician to document

Before the request is sent, it helps if your chart clearly shows:

1. When your symptoms started and how they have changed.
2. Your exam findings.
3. Every treatment you have tried, for how long, and the result.
4. Any warning signs.
5. Why an MRI is the right next step and how it will change your care.

You can ask: “Does my chart show what my plan’s MRI policy requires?” Bring a copy of the policy if you have it.

How to get an MRI covered

1. Ask whether prior authorization is needed. Call the plan or ask the imaging center. Most plans require it for MRI.
2. Get the plan’s imaging policy. Ask for the criteria for the exact MRI ordered.
3. Make sure your chart matches it. Ask your clinician to document symptoms, exam findings and prior treatment.
4. Confirm the request was sent. Get the date and reference number from the ordering office.
5. Check the approval details. Match the approved body part, contrast and dates to the scheduled MRI.
6. If denied, appeal quickly. Ask for a peer-to-peer review and file an internal appeal with your clinician’s letter.

Timelines

• Prior authorization decision: Since January 1, 2026, Medicare Advantage, Medicaid and CHIP plans must decide urgent requests within 72 hours and standard requests within 7 calendar days (CMS: CMS-0057-F fact sheet).
• Internal appeal: generally within 180 days of the denial under the federal rule (29 CFR 2560.503-1(h)(3)(i)); in Kentucky, at least 180 days for most plans (KY DOI UM Review Guide (2026)); check your denial letter. See Kentucky and Indiana.
• External review: generally within 4 months of the final internal denial (federal and Kentucky); 120 days in Indiana.

If your symptoms are urgent, ask for an expedited review.

Sample appeal letter

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Plan name or imaging review company] — Appeals
[Address or fax from your denial letter]

RE: Appeal of MRI denial
Member name: [Name] · Member ID: [Number]
Reference / case number: [Number]
MRI requested: [e.g., MRI lumbar spine without contrast]
Ordering clinician: [Name, credentials]
Date of denial: [Date]

To the Appeals Department:

I am appealing your denial of the MRI listed above. Your letter says: "[exact reason]."

I meet your imaging criteria, [policy name or number]:
- Symptoms: [what, since when] — see [record, date].
- Exam findings: [findings] — see [record, date].
- Treatment already tried: [therapy / medicine, dates, result] — see [record, date].
- Why the MRI is needed now: [how it will change treatment].

My clinician's enclosed letter explains why the MRI is medically necessary and cites [guideline].

Enclosed:
- Letter of medical necessity from [clinician]
- Visit notes and therapy records from [dates]
- X-ray report from [date] (if any)
- Your denial letter

Please approve the MRI. If you uphold the denial, please give me the specific reason, the criteria used, and the steps for external review in writing.

[If urgent:] My clinician believes delay could harm my health. I request an expedited review.

Sincerely,
[Signature]
[Printed name]

What the process looks like

Here is how an MRI request usually moves, from order to scan. Your plan may differ.

1. Your clinician orders the MRI and documents why.
2. The ordering office or imaging center sends the prior authorization request to your plan or its imaging review company.
3. The plan reviews it against its imaging policy. Many plans covered by the 2026 federal rule must decide within 7 calendar days (72 hours if urgent).
4. The plan approves, asks for more information, or denies. A request for more information is not a denial. Respond quickly.
5. If approved, you schedule the MRI within the approved dates.
6. If denied, your clinician can ask for a peer-to-peer and you can file an appeal.

An example

*This is an illustrative example, not a real patient.*

Sam has low back pain that runs down one leg. Sam’s clinician orders an MRI after two visits. The plan denies it as “not medically necessary.” The letter says conservative treatment was not documented.

Sam asks for the plan’s imaging policy. It lists a period of physical therapy or other treatment first, unless there are warning signs. Sam had done several weeks of physical therapy at another clinic, but those notes were never sent.

Sam’s clinician writes a letter that lists each criterion, and Sam’s appeal includes the therapy notes and the exam findings. The plan has everything it asked for this time. This is the most common way MRI denials are turned around: the missing proof is added.

Questions to ask before your MRI

• “Does my plan need prior authorization for this MRI?”
• “Who is sending the request, and when?”
• “Has it been approved? What is the reference number?”
• “Is it approved with contrast, without contrast, or both?”
• “Which body part and side were approved?”
• “What is my cost after insurance? Is there a cash-pay price?”

Common mistakes

• Scheduling before approval comes through. If the plan denies it later, you may owe the bill.
• A mismatch between approval and test. The approved body part, side and contrast must match the scan you get.
• Missing therapy or treatment notes, especially from another clinic.
• Not asking about a peer-to-peer. It can be faster than a written appeal.

What your denial letter should tell you

Since January 1, 2026, Medicare Advantage, Medicaid and HealthCare.gov Marketplace plans must give a specific reason when they deny a prior authorization request. A vague reason makes an appeal harder, so it is fair to ask for more detail.

When you get a denial for an MRI, check that the letter tells you:

• The exact service that was denied and the date.
• The specific reason, in words you can act on.
• The policy or criteria the plan used. If it doesn’t, ask for a free copy (29 CFR 2560.503-1(g)(1)(v); 45 CFR 147.136(b)).
• Your deadline to appeal and how to send it.
• How to ask for an expedited review if it’s urgent.
• How to ask for an external review if the internal appeal fails.

If anything is missing, call the plan, ask for it in writing, and write down the date, the name of the person you spoke with, and a reference number.

Costs and your deductible while you wait

An appeal can take weeks. Meanwhile, it helps to understand what you might owe either way.

• If the appeal succeeds, the plan pays under your normal benefits. You still owe any deductible, copay or coinsurance. See how your deductible works.
• If you go ahead before a decision, you may owe the full bill if the appeal fails. Ask for a written cost estimate first.
• Check your EOB when the claim is processed. It shows what was billed, allowed and owed. See how to read your EOB.
• Ask about payment plans if a large bill arrives during the appeal. Ask the billing office to hold the account while the appeal is open.

If coverage doesn’t work out

You still have options:

• Ask for an external review after a final internal denial.
• Ask about a cash-pay price. Aptiva publishes cash-pay prices for many services, including imaging. See cash-pay and self-pay options.
• Ask your clinician about other next steps while you wait.

Before paying cash, ask how it affects your deductible. Cash payments may not count toward it unless your plan allows that.