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This is a real-world style example: a denied MRI for "not medically necessary." Below is everything Claims Copilot would generate for you.
Source document
denial-letter.pdf
Classified as denial_letter · high confidence
PatientJordan Rivera
Member IDABC123456789
InsurerBlue Shield PPO
Date of serviceMar 14, 2026
Claim #CL-9921-447
ServiceMRI — Lumbar spine (CPT 72148)
Billed$2,340.00
Patient responsibility$2,340.00
Denial code50 — Not medically necessary
Appeal deadline180 days from notice
Sample data. Names, IDs, and amounts are fictional.
Plain-English summary
Your insurer denied a $2,340 lumbar MRI from March 14, 2026, saying it was "not medically necessary." You currently owe the full amount. Your plan allows you to file an internal appeal within 180 days.
Confirmed facts
- Service was an MRI of the lumbar spine, CPT 72148.
- Provider is in-network with Blue Shield PPO.
- Denial reason as written: "Service does not meet medical necessity criteria per plan policy MED-RAD-0034."
- Appeal deadline: 180 days from the date on the notice.
Possible issues to verify
- The denial cites policy MED-RAD-0034 but doesn't list the specific criteria you failed.
- It's unclear whether your provider submitted prior conservative treatment notes (e.g., 6 weeks of physical therapy).
- No peer-reviewed clinical guideline is cited in the denial.