Imaging Records for Insurance Prior Authorization
How do I get my insurance to approve my MRI or CT scan?
Submit your doctor's order, clinical notes, and any prior imaging showing medical necessity with the prior authorization request. If denied, you have the right to appeal with a letter of medical necessity and supporting records within 60-180 days.
Your doctor has ordered an MRI, but before you can schedule it, the imaging center says they need "prior authorization" from your insurance company. This process has become a frustratingly common gatekeeper to accessing advanced medical imaging. Understanding how it works—and the role your records play—can help you get your scan approved.
Why is Prior Authorization Required?
Insurance companies require prior authorization for expensive services to prevent overuse and control costs. From their perspective, they want to avoid paying for a $2,000 MRI if a $200 X-ray or a course of physical therapy would be just as effective.
Services That Typically Require Prior Authorization
Basic imaging like X-rays and most ultrasounds rarely require prior authorization.
The Prior Authorization Process
Doctor Orders Scan
Your doctor determines that you need an advanced imaging study and places an order.
Provider Submits Request
The doctor's office or imaging facility submits a prior authorization request to your insurance company, including your diagnosis and the specific scan being ordered.
Submission of Clinical Documentation
This is the most critical step. The provider must send relevant portions of your medical record to prove the scan is medically necessary:
- • Office visit notes detailing your symptoms and physical exam
- • Results of any prior, less-expensive imaging (like an X-ray)
- • Documentation of other treatments tried (like physical therapy or medication)
Insurer Review
A clinical reviewer at the insurance company (often a nurse) compares the submitted documentation against their internal guidelines.
Decision
The request is either approved or denied. If denied, the insurer must provide a reason.
Common Reasons for Prior Authorization Denials
A denial does not necessarily mean you don't need the scan. It often means the documentation was insufficient.
Insufficient Clinical Information
The submitted records did not clearly demonstrate the medical necessity of the scan. Solution: Ensure your doctor includes detailed clinical notes.
Step Therapy Not Followed
The insurer's policy requires you to try and fail a less expensive treatment first (e.g., six weeks of physical therapy before an MRI for back pain).
Wrong Scan Ordered
The reviewer believes a different type of scan would be more appropriate. This is common when ordering CT vs. MRI.
Administrative Errors
The request was submitted with the wrong billing code or was missing information. Often easily fixed with resubmission.
Your Role in the Process
While your doctor's office handles the submission, you can play a role in ensuring a smooth process.
Ensure Complete Records
Make sure your doctor has all your relevant records, especially from other providers, so they can submit a complete clinical picture.
Follow Up
Don't be afraid to follow up with your doctor's office to ensure the request has been submitted and to ask if additional information was requested.
If Denied, Appeal
You have the right to appeal a denial. This often involves a "peer-to-peer" review where your doctor speaks directly with a medical director at the insurance company.
Know the Reason
If denied, request the specific reason in writing. This tells you exactly what documentation is missing so you can address it in an appeal.