How to Appeal a Aetna Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) of the Spine Denial

What Aetna requires for coverage

Aetna considers Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) of the Spine medically necessary when the following criteria (from CPB 0236) are met:

• Aetna considers MRI and CT of the spine medically necessary when ANY of the following criteria is met:
• Clinical evidence of spinal stenosis
• Clinical suspicion of a spinal cord or cauda equina compression syndrome
• Congenital anomalies or deformities of the spine
• Diagnosis and evaluation of lumbar epidural lipomatosis
• Evaluation of recurrent symptoms after spinal surgery
• Evaluation prior to epidural injection to rule out tumor or infection and to delineate the optimal anatomical location for performing the injection
• Follow-up of evaluation for spinal malignancy or spinal infection
• Known or suspected myelopathy (e.g., multiple sclerosis) for initial diagnosis when MRI of the brain is negative or symptoms mimic those of other spinal or brainstem lesions
• Known or suspected primary spinal cord tumors (malignant or non-malignant)
• Persistent back or neck pain with radiculopathy as evidenced by pain plus objective findings of motor or reflex changes in the specific nerve root distribution, and no improvement after 6 weeks of conservative therapy*
• Primary spinal bone tumors or suspected vertebral, paraspinal, or intraspinal metastases
• Progressively severe symptoms despite conservative management
• Rapidly progressing neurological deficit, or major motor weakness

…and 7 more criteria in the full policy.

Covered procedure codes

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the CPB 0236 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Aetna either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Aetna medical policy CPB 0236 — view the published policy.