Strong case. Denials with this exact code and your plan language are overturned 81% of the time on appeal. We'll handle filing and follow-up.
Denial code CO-197 means the insurer claims no prior authorization. But your plan documents show this scan didn't require one — a reversible administrative error. I drafted an appeal citing the exact clause and the medical-necessity standard.
Re: Appeal of Claim #BS-4471902 (MRI, lumbar)
To the Appeals Department,
I am formally appealing the denial of claim #BS-4471902. The denial cites CO-197 (no prior authorization). However, per Section 6.2 of my Evidence of Coverage, advanced imaging ordered following a documented course of conservative treatment is exempt from pre-authorization. The service also meets the plan's medical-necessity standard per the ordering physician's notes (attached).
I request the denial be overturned and the claim reprocessed within the timeframe required under 29 CFR §2560.503-1.
— Generated for Ronen · reviewed & ready to file
✓Cited your specific plan clause + federal appeal-timeline rule
✓Attached the medical-necessity documentation automatically
✓Files to the correct address before your 180-day deadline
No win, no fee. 20% of recovered amount applies only if your appeal succeeds.
Blue Shield · MRIClaim #BS-4471902 · $1,420
CURRENT STATUS
Under insurer review
Decision expected by Jun 24 · we're on it
Case timeline
✓
Denial scanned & analyzed
Code CO-197 identified · Jun 10
✓
Appeal drafted & approved
You tapped "File this appeal" · Jun 10
✓
Filed to Blue Shield
Confirmation #AP-99231 · Jun 11
●
Insurer reviewing
Agent following up every 5 days
$
Payment recovered
Our 20% fee applies only if you win
🎉
Appeal won!
+ $1,420
Blue Shield overturned the denial. Your $1,420 is being reprocessed and will hit your account in 3–5 days.
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