Nivellark · U.S. patient resource
A checklist for your imaging appeal packet
An imaging denial may concern approval before a scan or payment for imaging already received. The plan’s notice identifies the decision and its submission instructions. These examples are not a required list for every plan; include items related to the decision and follow the plan’s instructions.
Records to consider
Choose what applies
Full denial notice
Keep the entire notice, including the reason for the decision and review instructions.
Explanation of Benefits (EOB), if issued
Include the EOB when the issue concerns payment for a scan that has already happened.
Plan appeal instructions and any required form
Use the form or submission method named in the notice, if the plan requires one.
Imaging order or referral
Gather the order or referral related to the scan under review.
Relevant prior-authorization messages
Include related requests, approvals, or denial messages when authorization is at issue.
Relevant clinical notes
Ask the treating clinician or provider for notes that relate to the reason in the notice.
Clinician’s supporting letter, if available
A clinician may be able to explain why the requested imaging is appropriate and address the denial reason.
Imaging report, if the scan was completed
Include the report when it is relevant to the decision being reviewed.
Copy of the appeal request and supporting records
Keep a copy of the request and everything included with it.
Submission confirmation or other proof
Save confirmation showing how the appeal was sent for your own records.
This is general information, not legal or medical advice. It does not decide coverage or predict an appeal outcome. Follow the instructions in your own notice and plan materials. Keep copies of what you send and save submission confirmation for your records.