Lakeside Neurology Associates
1820 Lakeshore Avenue, Suite 210
Oakland, CA 94606
(510) 555-0147
June 13, 2026
Anthem Blue Cross
Grievance and Appeals Department
Re: Appeal of claim ANT2026041387721 — CPT 70553 (MRI of the brain, without and with contrast); denial CO-50
Lakeside Neurology Associates formally appeals the denial of claim ANT2026041387721 and requests reconsideration. The MRI of the brain performed without and with contrast (CPT 70553) was denied on April 10, 2026 as not medically necessary (CO-50, RARC N115). We respectfully request that Anthem overturn the determination, reprocess the claim, and remit payment for CPT 70553 at the applicable allowed amount. This appeal is submitted within the plan's applicable ACA appeal window, and the exact filing deadline should be confirmed against the denial notice.
Why the MRI was medically necessary
The denial rests on a conclusory medical-necessity determination that the documented clinical presentation does not support. The brain MRI was ordered to evaluate a primary headache disorder (ICD-10 G43.909) in a setting with several features that warrant advanced neuroimaging: symptoms new or worsening across more than twelve weeks, an adequate trial of pharmacologic therapy with an inadequate clinical response, and objective focal or abnormal findings on examination together with red-flag warning signs. The study was ordered on an urgent basis.
The coverage criteria applied by the Medicare contractor for this provider's jurisdiction are instructive as persuasive evidence of the generally accepted clinical standard, and this patient satisfies them. The applicable Local Coverage Determination recognizes that advanced head imaging should be
reserved for the patient whose presentation indicates a focal problem or who has experienced a significant change in symptomatology.
. The examination documented focal findings, and the clinical course reflected a significant change in symptomatology rather than a stable, longstanding headache pattern. The study was performed without and with contrast because contrast administration is appropriate to characterize a specific lesion and to detect defects in the blood/brain barrier. Contrast was integral to the specific concerns this presentation raised. Taken together, the documented duration, the failed pharmacologic management, the focal examination findings, and the red-flag features establish that the brain MRI was a reasonable and clinically necessary step in the workup. The EOB's bare statement that the service is not deemed a medical necessity does not engage any of these documented facts and identifies no specific coverage criterion the service is said to fail.
We are available to discuss this case directly with the plan's reviewing physician through a peer-to-peer review, and would welcome that opportunity to address any specific clinical question the reviewer may have.
The plan owes a full and fair review
As a non-grandfathered ACA plan, Anthem must afford the claimant a full and fair internal appeal. Federal law requires the plan to , and the implementing regulation provides that a plan and issuer . If this internal appeal is upheld, the patient retains the right to external review through an Independent Review Organization — in California, administered by the Department of Managed Health Care, filed within 120 days of the final internal denial.
Request
For these reasons, we request reversal of the CO-50 denial, reprocessing of claim ANT2026041387721, and payment for CPT 70553 at the applicable allowed amount. Please provide a written determination within 30 days of receipt. Should the denial be upheld, the patient and practice intend to pursue external review through the California Department of Managed Health Care. Supporting documentation is enclosed.
Sincerely,
Sarah Chen, MD
NPI 1379246808
Lakeside Neurology Associates
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