What is a peer-to-peer review and how do I get one?

A peer-to-peer is a direct conversation between the physician who ordered the scan and the reviewing clinician who issued the denial. Only the ordering clinician's office can request it — you cannot book it yourself — so the useful step is to call the office, say the imaging was denied, and ask them to request a peer-to-peer. Availability and timeframes depend on the plan or the review organization handling the request.

The denial says to try conservative treatment first. What counts?

Plans that apply a conservative-care requirement generally want documented, dated treatment rather than a description of symptoms — physical therapy visits, medication trials, activity modification, injections, and what changed. Much of it may already exist in your chart or your physical therapist's notes. The exact requirement varies by plan, so ask for the written criteria and answer them specifically.

Who actually denied my scan?

Many plans delegate advanced-imaging review to a separate radiology benefit-management organization, so the denial may come from a company you have never heard of and the criteria may be theirs rather than the insurer's. Ask which entity made the determination, and request the specific criteria that entity applied. Your appeal rights still run through the plan.

Can I just pay for the scan myself and get reimbursed later?

Paying privately is sometimes reasonable when a delay is unacceptable, but it may weaken a later reimbursement claim, since plans commonly refuse services obtained without required prior authorization. If time allows, get the coverage decision in writing first. If you do pay privately, keep the order, the report, and the receipt, and ask the plan in writing what it needs for post-service review.

MRI or CT denied: what the reviewer is actually asking

UPDATED SEPTEMBER 1, 2026 · U.S. PLANS · NOT LEGAL OR MEDICAL ADVICE

Most advanced-imaging denials are not a judgement that you do not need the scan. They are a judgement that the file did not yet show what the reviewer's checklist asked for. That distinction matters, because the fastest route back is usually not a written appeal at all — it is a peer-to-peer review, and only your doctor's office can request it.

The two denials you are most likely holding

"Conservative treatment not documented" — the plan wants a period of non-imaging treatment, with dates, before it authorises the scan.
"Criteria not met" — the request did not match the specific clinical criteria the reviewer applied. Ask which criteria, in writing.
"Not medically necessary" — generic wording that usually resolves into one of the two above once you ask for the rationale. See the medical-necessity guide.
"No prior authorization" — a process failure rather than a clinical judgement, and often fixable. See the prior-authorization guide.

Step 1 — Ask your doctor's office for a peer-to-peer

A peer-to-peer is a direct conversation between the clinician who ordered the scan and the reviewing clinician who denied it. It exists precisely because a checklist cannot capture everything in a chart, and it is frequently the quickest way to resolve an imaging denial — sometimes in a single call, without a formal appeal.

You cannot request one yourself. Call the ordering clinician's office, tell them the imaging was denied, and ask them to request a peer-to-peer with the reviewer. Ask when the window closes: some plans and review organizations only offer it for a limited period after the determination, and once that passes the written appeal becomes the route. Ask the office to note the reviewer's name and the reason given, whatever the outcome — if it stays denied, that reason is what the written appeal has to answer.

Step 2 — Find out who actually denied it

Many plans delegate advanced-imaging decisions to a separate radiology benefit-management organization. The determination may therefore come from an entity you have no relationship with, applying its own published criteria rather than the insurer's. This is worth establishing early, because you want the right criteria in front of you.

Ask the plan, in writing: which entity made the determination, which specific criteria were applied, and for a copy of those criteria. Requesting the rule you are being measured against is a normal part of an appeal, and having it turns a vague disagreement into a checklist you can answer.

Step 3 — Build the record the criteria asked for

If the denial cites conservative care, the appeal is largely an evidence-assembly exercise. Reviewers applying this kind of rule generally want dated, documented treatment rather than a narrative of how much pain you are in. Collect what already exists:

Physical therapy — visit dates, number of sessions, the therapist's progress notes, and what did or did not improve.
Medication trials — what was prescribed, at what dose, for how long, and the effect.
Other measures — activity modification, bracing, injections, home programmes, with dates.
The clinical picture over time — examination findings across visits, especially anything that has changed or worsened.
Any findings your clinician considers urgent — if your clinician documents features that in their judgement make waiting inappropriate, that belongs in the file and may support an expedited request.

Two practical notes. First, much of this already exists somewhere other than your doctor's chart — physical therapy clinics keep their own notes, and you can request them. Second, gaps are often bookkeeping rather than fact: a course of therapy that happened but was never summarised into the referral is a common reason a file looks thin to a reviewer.

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Step 4 — File the written appeal, and keep the deadline

If the peer-to-peer does not resolve it, file the internal appeal against the specific reason given. Answer the criterion in the reviewer's own terms, attach the source documents rather than describing them, and ask your clinician for a short statement explaining why imaging is the appropriate next step now rather than after further conservative care.

Watch the clock from the date on the notice, not the date you opened it. The step-by-step guide covers the filing window and how to prove you filed on time.

If waiting is not safe

If the ordinary timeframe could seriously jeopardize your life, health, or ability to regain maximum function under the plan's urgent-care standard, ask for an expedited appeal and have your clinician state why in writing. Many commercial plans subject to federal claims rules use a 72-hour urgent-care deadline, though plan and program rules differ. Expedited review generally has to be requested explicitly — it is not applied automatically because a case sounds serious.

If the internal appeal fails

Imaging denials are clinical disagreements, which is the category external review exists for. After a final internal denial, an eligible dispute can go to a reviewer independent of the plan, and under the applicable process that decision binds the insurer. Check the window stated in your final denial and preserve it.

Frequently asked questions

My doctor says the scan is necessary. Why does that not settle it?

The plan is not deciding what care you should have — it is deciding what it will pay for, against written criteria. Your clinician's judgement is central evidence, but it works best when it is tied explicitly to the criterion the reviewer applied, with the supporting documentation attached.

The denial letter gives no real reason. What do I do?

Ask for one in writing: the specific criteria applied, the entity that applied them, and the clinical rationale for the determination. You are entitled to understand the basis of an adverse decision, and a vague notice is not something you should have to guess at.

Does it help to have the imaging centre call?

They can sometimes clarify coding or scheduling, but they cannot make the clinical argument. A peer-to-peer requires the ordering clinician, because the discussion is about your clinical picture rather than the booking.

The scan was denied after it was already done. Is that different?

Yes. A post-service denial is a payment dispute rather than an authorisation one, and the timeframes and process can differ. Do not pay a balance before establishing whether the plan or the provider is responsible under the contract — start with a written explanation of the denial reason.