1. DENIAL CLASSIFICATION — Medical necessity. Anthem is asserting that your chart does not document enough conservative treatment before advanced imaging. This is a documentation dispute, not a coverage exclusion: the plan does cover lumbar MRI, but only after a conservative-care trial. Notably, the denial does not say conservative care was absent, only that it was not documented for the required duration. 2. STRENGTH ASSESSMENT — Strong. You have 8 weeks of physical therapy plus 6 weeks of medication therapy, which meets or exceeds the 6-week conservative-care trial most plans require before lumbar MRI. More importantly, you have a new focal neurologic finding, left-foot numbness with a positive straight-leg-raise, which is a red-flag symptom that under most imaging criteria justifies advanced imaging regardless of how long conservative care ran. The likely cause of this denial is that the PT and medication records simply never reached the reviewer. 3. EVIDENCE CHECKLIST - Physical therapy discharge summary and visit notes, January to March — proves duration and non-response. Request from your PT clinic's records desk. - Pharmacy printout for the NSAID and steroid taper — proves the medication trial and its dates. Free from your pharmacy. - Orthopedist's office note from the visit that ordered the MRI — this is the key document; it should record the positive straight-leg-raise and the new numbness. Request from the ordering provider. - Letter of medical necessity from the orthopedist — should explicitly state the failed conservative trial, the new neurologic deficit, and why imaging changes management. - Your Summary Plan Description section on advanced imaging — establishes the actual conservative-care requirement so you can show it was met. 4. APPEAL PATH AND DEADLINES — File a level-one internal appeal now. Employer PPO plans governed by ERISA generally allow two internal levels, after which you may request an independent external review. Your 180-day window runs to roughly 2026-11-24, so you have time, but file within 30 days while the records are easy to pull. An expedited appeal is not warranted here: your symptoms are significant but not emergent. If the numbness progresses to weakness, foot drop, or any bladder or bowel change, stop and seek emergency care, and then an expedited appeal does apply. 5. THE APPEAL LETTER Anthem Blue Cross Appeals and Grievances Department {insert appeals address from your denial letter} Re: Level One Internal Appeal Member: {insert your full name} Member ID: {insert your member ID} Group Number: {insert your group number} Claim Number: RX-88401255 Date of Service: May 12, 2026 To the Appeals Review Committee, I am appealing the denial of coverage for a lumbar spine MRI without contrast performed on May 12, 2026, billed at $2,340. The denial states that services were not medically necessary because conservative treatment was not documented for the required duration prior to advanced imaging. The enclosed records show that conservative treatment was completed and documented, and that an independent indication for imaging was present. First, conservative care was completed. I underwent eight weeks of supervised physical therapy from January through March 2026 without improvement, documented in the enclosed discharge summary and visit notes. I concurrently completed a six-week course of NSAID therapy and a corticosteroid taper, documented in the enclosed pharmacy record. This meets the conservative-care trial described in the plan's advanced imaging provision, enclosed. Second, and independently, a new focal neurologic finding was present. At the visit that generated this order, my orthopedist documented a positive straight-leg-raise test and new numbness in the left foot, consistent with lumbar nerve root compression. Standard imaging criteria treat a new or progressive neurologic deficit as an indication for advanced imaging irrespective of the length of conservative care. The enclosed letter of medical necessity from the ordering physician addresses this directly. The denial appears to rest on an incomplete record rather than on a determination that care was not delivered. With the enclosed documentation, the medical-necessity criterion is satisfied. I request that you overturn this denial and process claim RX-88401255 for payment at the in-network benefit level. Please provide a written determination within 30 days as required for an internal appeal. If this appeal is denied, please include the specific plan provision relied upon and instructions for requesting independent external review. Enclosures: PT discharge summary and visit notes; pharmacy record; orthopedist office note dated {insert date of the visit that ordered the MRI}; letter of medical necessity; Summary Plan Description excerpt. Sincerely, {insert your name} {insert your phone number and address} Placeholders to fill before sending: appeals address, your full name, member ID, group number, the ordering visit date, your phone number and address. 6. NEXT STEPS - Call the member services number on your card and request the plan's written medical-necessity criteria for lumbar MRI, plus written confirmation of the appeal deadline. Ask for it in writing, by mail or portal message. - Request the PT records and the orthopedist's office note today; records departments commonly take 7 to 14 days. - Ask the orthopedist's office to write the letter of medical necessity, and give them the denial language so they address it directly. - Send the appeal by a method that produces proof of delivery, and keep a copy of everything including the mailing receipt. - Log every phone call with the date, the representative's name, and a reference number.