Medicare Advantage Denied Your MRI or CT Scan? How to Appeal

Your doctor said you need an MRI or CT scan. Maybe your back pain has lasted months, or a new symptom needs answers. Then your Medicare Advantage plan sent a letter that said no, or said "not yet." That letter does not have to be the end of the story.

Advanced imaging like MRI and CT scans is among the services Medicare Advantage plans most often require prior authorization for. That means a denial here is one of the most common reasons people end up appealing, and it is also one of the most winnable.

Why Imaging Gets Denied So Often

It helps to understand how these denials usually happen. In most cases, the plan is not saying the scan is unnecessary forever. It is saying the request, as submitted, did not meet the plan's specific coverage criteria. That is a very different problem, and it is one you can often fix.

Two patterns show up again and again:

• Conservative treatment requirements. Many plans require documentation that less invasive options, like physical therapy, medication, or rest, were tried first and did not work before they approve advanced imaging.
• Documentation gaps. The request may not have clearly spelled out the symptoms, how long they have lasted, prior treatments, or the specific clinical question the scan is meant to answer.

In other words, many MRI and CT denials are about what the request documented, not about whether the scan is medically needed. That reframing matters because it tells you exactly what to fix when you appeal: give the plan the specific information it says is missing.

Step 1: Read the Denial Notice Closely

Your Medicare Advantage plan is required to send a formal denial notice called the Notice of Denial of Medical Coverage or Payment, often called the Integrated Denial Notice. Find two things on it right away:

• The stated reason for denial. This is usually a specific clinical criterion the plan says was not met.
• The deadline to appeal. This is printed on the notice and matters a great deal, because it is a hard clock.

Medicare Advantage plans send an Explanation of Benefits, not a Medicare Summary Notice. The Medicare Summary Notice only goes to people with Original Medicare, so do not expect one if you have a Medicare Advantage plan.

Step 2: Ask for a Peer-to-Peer Review First

Before you file a formal appeal, ask the doctor who ordered the scan to request a peer-to-peer review. This is a conversation between your doctor and the plan's medical reviewer, and it often resolves imaging denials quickly because it lets your physician explain the clinical reasoning directly to someone with medical training on the other end.

A peer-to-peer review is not a substitute for a formal appeal and does not pause your appeal deadline, so do not wait to find out how it goes before you also prepare a written appeal. Think of it as a fast first move you make while the appeal clock is still running.

Step 3: File a Level 1 Appeal With a Strong Letter of Medical Necessity

If the peer-to-peer does not resolve things, or your doctor is unable to get one scheduled quickly, move to a formal Level 1 appeal, called a plan reconsideration.

The Deadline

For Medicare Advantage, the Level 1 appeal must be filed within 65 calendar days of the date on the denial notice. This is measured from the date printed on the notice itself, not from when you received it, so you do not have to guess when the letter arrived in your mailbox. If you miss this window, you can ask the plan for a good-cause extension, but it is best not to rely on that and to file as soon as you can.

What to Include

Your appeal should include a letter of medical necessity that directly answers the plan's stated reason for denial. Do not just restate that you need the scan. Instead, address the specific criteria the plan cited:

• What conservative treatments were already tried, for how long, and what the results were.
• The specific symptoms and how they affect your daily function.
• The precise clinical question the scan is meant to answer, such as ruling out a specific diagnosis or guiding a treatment decision.
• Any relevant exam findings, prior test results, or specialist notes that support the request.

For help structuring this, see our letter of medical necessity guide, and use our Medicare denial appeal letter template to make sure you include everything the plan needs to reconsider the request.

Step 4: Ask for Expedited Review If Waiting Could Hurt You

If waiting for a standard decision could seriously jeopardize your health or your ability to regain maximum function, you can request an expedited appeal. This is different from an expedited request for initial coverage, so it helps to keep the two clocks straight.

• Expedited initial request (before any denial): if you are asking your plan to approve the scan quickly in the first place, that is called an organization determination, and it runs on its own faster clock.
• Expedited appeal (after a denial): once you are appealing an actual denial and ask for expedited review, Medicare Advantage plans must decide within 72 hours. This 72-hour timeframe applies to all expedited Medicare Advantage appeals, including appeals involving Part B drugs. There is no shorter exception at the appeal stage.

To ask for expedited review, tell your plan clearly, in writing or by phone, that your doctor believes waiting for a standard decision could seriously harm your health, and ask that the request be reviewed on an expedited basis. Your doctor's support for the expedited request can carry real weight, so it helps to have them confirm this urgency in writing as well.

What Happens if the Plan Still Says No

If the plan upholds its denial at Level 1, it does not require you to file anything new to move forward. Medicare Advantage denials upheld at Level 1 are automatically forwarded to the Independent Review Entity, the IRE, which is a separate contractor that reviews the case independently. This is different from Original Medicare, where appeals go to a Qualified Independent Contractor, the QIC. The terms are not interchangeable, so if you are researching further levels, make sure the information you are reading matches Medicare Advantage rather than Original Medicare.

Don't Give Up on the Appeal

It can feel discouraging to get a denial letter, especially when you are already dealing with pain or an unresolved health concern. But appealing is often worth the effort. According to a 2024 KFF analysis, roughly 80% of appealed Medicare Advantage prior-authorization denials are overturned. That same analysis found that only about 11.5% of denied Medicare Advantage prior-authorization requests are actually appealed, which means many people who could win an appeal never file one.

If you are newly enrolled in a Medicare Advantage plan and were already undergoing treatment related to the condition the scan is meant to evaluate, ask the plan in writing about your transition protections. Plans must generally allow a transition period of at least 90 days for an active course of treatment without disrupting it or requiring reauthorization, even if the provider is out of network. Confirm the specifics with your plan directly, since this is a minimum and some plans may offer more.

Coverage rules and prior-authorization requirements reset each plan year, so a scan that was covered without trouble last year can suddenly require more documentation this year, even if nothing about your health has changed. This is a normal part of how Medicare Advantage plans operate, not a sign that something went wrong with your case specifically.

Final Reminders

Always check the deadline printed on your own denial notice, since this article describes the standard Medicare Advantage timeline but your notice is the controlling document. For the most current rules, deadlines, and plan details, confirm information directly at Medicare.gov or by calling 1-800-MEDICARE.

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This article is general education, not legal or medical advice. Medicare rules, deadlines, and dollar amounts change; confirm the current details for your situation at Medicare.gov or by calling 1-800-MEDICARE. MedicareClaimDenied.com is not affiliated with or endorsed by Medicare, CMS, or any insurer.