MRI or CT of the back denied by insurance: next steps in Texas
Updated November 5, 2026.
In short
- Two different cases: a scan not yet done that the plan would not approve, and a bill for a scan already done that the plan would not pay.
- For a scan not yet done, letters often cite a rule asking for other treatment first for a set time. If that time has not passed, an appeal cannot change it; the ordering office can send a new request once it has passed.
- A denied bill can be appealed. Most plans give 180 days to file; Medicare Advantage, 65 days from the notice date.
Free during our test. No payment card. No charge later. The first 20 Texas adults are included.
This page covers MRI and CT of the back and neck. Whether a scan is needed is for the treating doctor to say.
Which case the letter describes
| Scan not yet done | Bill for a scan already done | |
|---|---|---|
| Appeal answer, job-based and Marketplace | Up to 30 days | Up to 60 days |
| Medicare Advantage answer | 30 days; 72 hours if expedited | 60 days; no fast route |
| TDI's own outside review, when the letter names it ("TDI" or "DOI" plans) | 20 days; 3 if life-threatening | 20 days |
A scan not yet done: "other treatment first"
Letters about a scan not yet done often cite a rule asking for other treatment first, such as physical therapy or medicine, for a set time. The words may be "conservative treatment" or "conservative management". Job-based and Marketplace plans must give a free copy of any criterion relied on (29 CFR 2560.503-1(g)(1)(v)(A)).
Two problems can sit behind it: the treatment happened but the papers did not show it, or the rule's time has not passed yet.
Why the doctor's office is often the fastest path
- The ordering office usually sends the approval request. It can send a new one once the rule's terms are met, and may already be asking for a second look.
- A standard appeal for a scan not yet done can take 30 days (29 CFR 2560.503-1(i)(2)(ii); Medicare.gov). When the rule's waiting time ends sooner, a new request is often quicker.
- If waiting could seriously harm health, the 72-hour route can apply (29 CFR 2560.503-1(m)(1); 42 CFR 422.584(c)). Denial Reply does not take those cases.
When an appeal fits
An appeal answers the other problem: the treatment already happened, but the plan did not get the proof, such as dated therapy notes, medicine lists or visit notes. For a "not medically necessary" letter, job-based and Marketplace plans must give the clinical reasons free on request (29 CFR 2560.503-1(g)(1)(v)(B)).
A bill for a scan already done
- Job-based plans: at least 180 days to file; the plan decides within 60 days, or 30 for each of two levels (29 CFR 2560.503-1(h)(3)(i), (i)(2)(iii)).
- Marketplace plans: 180 days to file; 60 days to decide (HealthCare.gov).
- "TDI" or "DOI" on the card: the letter gives the date. TDI's own outside review, when the letter names it, also covers care already given, and the plan pays its fee (TDI's IRO FAQ).
- Medicare Advantage: 65 days from the notice date (42 CFR 422.582(b)); 60 days to decide; no fast route for payment (42 CFR 422.584(a); 422.590(b)).
- A bill appeal usually includes the Explanation of Benefits, the denial letter, the office's notes on why the scan was ordered, and a claim-file request (HealthCare.gov; 29 CFR 2560.503-1(h)(2)(iii)). The billing office may have appealed already.
If the plan says no again
Outside review depends on the plan and the decision. "TDI" or "DOI" plans: Follow the external-review instructions your denial letter must give you (Texas Insurance Code 4201.303 requires them for TDI or DOI plans). The route can be TDI's own independent review organization or the federal external review process. Self-funded job plans: federal external review within 4 months (45 CFR 147.136). Marketplace plans: state or federal; the final letter must say which and how. Medicare Advantage: automatic review (42 CFR 422.590).
Free public help
- Texas Department of Insurance: 800-252-3439. Office of Public Insurance Counsel (OPIC): 1-877-611-6742.
- U.S. Labor Department, Dallas (self-funded job plans): 972-850-4500.
- 1-800-MEDICARE (1-800-633-4227). Texas Medicare help line: 800-252-9240.
What Denial Reply prepares
Denial Reply prepares appeal paperwork for Texas adults for denied bills for back or neck MRI or CT scans, and for scans not yet done once the treatment the rule asks for has happened. Otherwise it points to the doctor's office and the free lines. The free decoder at /decode needs no upload.
Related guides: which appeal route applies in Texas · asking for the claim file and criteria
Who, how, why
- Who: Denial Reply. Drafted with AI and checked by the founder, who is not a doctor and is not licensed to practice law.
- How: From the federal rules and government pages below, read November 3, 2026, and Texas Insurance Code 4201.303 and the CMS list of state external review processes, read November 5, 2026. No insurer's criteria were used.
- Why: To set out the Texas steps for these denials. It is general information, not legal or medical advice.
Sources
- 29 CFR 2560.503-1 and 45 CFR 147.136: https://www.law.cornell.edu/cfr/text/29/2560.503-1 and https://www.law.cornell.edu/cfr/text/45/147.136 (read 2026-11-03)
- 42 CFR 422.584, 422.590: https://www.law.cornell.edu/cfr/text/42/422.584 and https://www.law.cornell.edu/cfr/text/42/422.590 (read 2026-11-03)
- HealthCare.gov: https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (read 2026-11-03)
- Medicare.gov: https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans (read 2026-11-03)
- OPIC: https://www.opic.texas.gov/health-insurance/get-help/appeal-denied-claim/ (no date shown; read 2026-11-03)
- Texas Insurance Code 4201.303: https://tcss.legis.texas.gov/resources/IN/htm/IN.4201.htm; CMS, state external review processes: https://www.cms.gov/cciio/resources/files/external_appeals (modified 08/14/2026; both read 2026-11-05)
- TDI, IRO FAQ (updated 9/13/2024) and self-funded plans (updated 6/23/2023): https://www.tdi.texas.gov/hmo/mcqa/irofaqs.html and https://www.tdi.texas.gov/consumer/selffundedplans.html (read 2026-11-03)