UnitedHealthcare decides coverage for Radiologic Diagnostic Procedures under policy MMP076.11. The most effective appeal shows, point by point, that you meet UnitedHealthcare's own criteria below.
What UnitedHealthcare requires for coverage
UnitedHealthcare considers Radiologic Diagnostic Procedures medically necessary when the following criteria (from MMP076.11) are met:
- Diagnostic imaging must be reasonable and necessary for diagnosis or treatment of illness/injury
- Specific sign, symptom, or patient complaint must be indicated for every diagnostic service billed
- Must meet medical necessity requirements in Medicare statute, regulations, manuals, NCDs and LCDs
- CT scan: Per NCD 220.1 coverage guidelines
- MRI: Per NCD 220.2 coverage guidelines - useful for diagnosing diseases of CNS, head/neck, body
- MRI covered when results will contribute to plan of treatment and not duplicative of prior exams
- Diagnostic ultrasound: Per NCD 220.5 - covered where use is not investigational
- For radiology prior auth program regions: must follow eviCore/UHC Radiology and Cardiology Clinical Guidelines
- For non-prior-auth regions: must follow InterQual CP: Imaging guidelines
Covered procedure codes
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the MMP076.11 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that UnitedHealthcare 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: UnitedHealthcare medical policy MMP076.11 — view the published policy.