How to Appeal a Anthem Blue Cross Blue Shield Advanced Imaging Clinical Appropriateness Guidelines (MRI, CT, PET) Denial

What Anthem Blue Cross Blue Shield requires for coverage

Anthem Blue Cross Blue Shield considers Advanced Imaging Clinical Appropriateness Guidelines (MRI, CT, PET) medically necessary when the following criteria (from Carelon/AIM Radiology Clinical Appropriateness Guidelines) are met:

• Advanced imaging services (MRI, CT, PET, nuclear medicine) require prior authorization through Carelon Medical Benefits Management
• Clinical appropriateness is determined using Carelon Clinical Appropriateness Guidelines developed through evidence-based literature integrated with expert physician review
• Imaging must be medically necessary based on clinical presentation and documented symptoms
• Ordering provider must submit prior authorization request via Carelon ProviderPortal (providerportal.com) - available 24/7 for real-time processing
• Clinical information supporting medical necessity must be provided at time of request
• Guidelines comply with applicable accreditation and legal standards

Covered procedure codes

70551	MRI brain without contrast
70552	MRI brain with contrast
70553	MRI brain without contrast followed by with contrast
70336	MRI temporomandibular joint(s)
70540	MRI orbit, face, and/or neck without contrast
70542	MRI orbit, face, and/or neck with contrast
70543	MRI orbit, face, and/or neck without then with contrast
70544	MRA head without contrast
70545	MRA head with contrast
70546	MRA head without then with contrast
70547	MRA neck without contrast
70548	MRA neck with contrast

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the Carelon/AIM Radiology Clinical Appropriateness Guidelines language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Anthem Blue Cross Blue Shield 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: Anthem Blue Cross Blue Shield medical policy Carelon/AIM Radiology Clinical Appropriateness Guidelines — view the published policy.