CASE-003

Section 1 of 4

What the payer refused, and why

Patient

Creola Heller

Payer

NORTHBECK HEALTH PLAN

Service denied

Magnetic resonance imaging, cardiac, with contrast material, including stress imaging and morphology CPT/HCPCS 75561 · ICD-10 R06.00

Payer's stated reason

The clinical information submitted does not establish that cardiac magnetic resonance imaging is medically necessary under the plan's applicable medical policy. The submitted records do not establish that the initial diagnostic evaluation was inconclusive for the clinical question posed. The echocardiogram report dated March 9, 2026 provides an ejection fraction estimate and the reviewer determined that this constitutes an adequate assessment of left ventricular function. The reviewer further notes that the submitted records do not address whether a contraindication to magnetic resonance imaging exists.

Section 2 of 4

The clinical argument, criterion by criterion

The patient is an 83-year-old female presenting with progressive exertional dyspnoea. An initial evaluation including a 12-lead ECG and a transthoracic echocardiogram was completed in March 2026 but proved technically inadequate and inconclusive. The treating cardiologist requested a cardiac magnetic resonance imaging study with contrast to resolve the differential diagnosis between infiltrative cardiomyopathy and ischaemic heart disease, detailing how the results will directly guide subsequent clinical management, and addressing the patient's permanent pacemaker relative contraindication.

Each row is a requirement in the payer's own policy, the verdict reached on it, and the chart text that verdict rests on. 5 of 8 are satisfied with evidence. Read the quotations against what you remember of the care. There is no confidence column: nothing you are about to sign changes at ninety-four percent rather than eighty-eight.
Criterion	Verdict	Chart evidence
NBH-CARD-014-3.1 The member has symptoms consistent with cardiac disease, including but not limited to chest pain, dyspnoea on exertion, syncope, or palpitations, that have persisted for at least six weeks, or that are documented as progressive.	Satisfied The patient reports progressive exertional dyspnoea that began on or before February 2026, persisting for over six weeks and documented as having worsened further by April 2026.	Eighty-three year old woman reporting six weeks of increasing breathlessness on exertion. enc/2026-02-18/internal-medicine Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. enc/2026-04-22/cardiology
NBH-CARD-014-3.2 An initial diagnostic evaluation has been completed and documented. This evaluation must include a twelve-lead electrocardiogram and a transthoracic echocardiogram performed within the twelve months preceding the request.	Satisfied Both a twelve-lead ECG and a transthoracic echocardiogram were completed in March 2026, which is within the twelve months preceding the April 2026 cardiac MRI request.	Twelve-lead electrocardiogram performed 2 March 2026. enc/2026-03-02/ecg Transthoracic echocardiogram performed 9 March 2026. enc/2026-03-09/echocardiogram
NBH-CARD-014-3.3 The results of the initial evaluation under section 3.2 are inconclusive, equivocal, or technically inadequate for the clinical question posed, and the treating clinician has documented what remains unresolved.	Satisfied The treating cardiologist documented that the echocardiogram was technically inadequate and that the diagnostic question regarding infiltrative cardiomyopathy versus ischaemic disease remains unresolved.	The echocardiogram is technically inadequate for the clinical question. enc/2026-04-22/cardiology The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically. enc/2026-04-22/cardiology
NBH-CARD-014-3.4 The requested study is expected to change clinical management, and the treating clinician has documented the specific management decision that depends on the result.	Satisfied The cardiologist explicitly documented that the cardiac MRI results will directly determine subsequent clinical management steps, specifically directing the patient either to amyloidosis workup/therapy or to invasive angiography for ischaemic disease.	the distinction determines management directly: a positive amyloid pattern would take her to bone scintigraphy and serum free light chains and, if confirmed, to disease-modifying therapy, whereas an ischaemic pattern of enhancement would take her to invasive angiography. enc/2026-04-22/cardiology
NBH-CARD-014-3.5 There is no contraindication to magnetic resonance imaging, or, where a relative contraindication exists, the medical record documents that it has been addressed.	Satisfied The treating cardiologist noted the patient's permanent pacemaker (a relative contraindication) and documented the necessary action to address it by confirming device details prior to scheduling the scan.	She has a permanent pacemaker; the device details will need to be confirmed with the implanting centre before scheduling. enc/2026-04-22/cardiology
NBH-CARD-014-4.1 The member presents with stable chest pain and an intermediate pre-test probability of coronary artery disease, as documented by a validated risk assessment tool.	Not satisfied The patient presents with progressive exertional dyspnoea rather than chest pain, and the record explicitly notes she has 'no chest pain'. Additionally, no validated risk assessment tool has been documented.	no chest pain enc/2026-02-18/internal-medicine
NBH-CARD-014-4.2 The member has not undergone coronary revascularisation, and no coronary stent is in place, unless the requested study is for the evaluation of graft patency.	Not satisfied The patient's problem list documents a history of coronary artery bypass grafting (CABG) in 2014, which represents a prior coronary revascularisation, and there is no documentation indicating that the requested imaging is for evaluation of graft patency.	No chart evidence cited
NBH-CARD-014-4.3 The member's heart rate is expected to be controllable to a rate suitable for the acquisition, or the imaging facility has documented capability for high-heart-rate acquisition.	Insufficient documentation The medical record does not contain any documentation addressing the controllability of the member's heart rate for CT acquisition or the capabilities of the imaging facility regarding high-heart-rate acquisition.	No chart evidence cited

6 criteria could not be evaluated at all

NBH-CARD-014-5.1, NBH-CARD-014-5.2, NBH-CARD-014-5.3, NBH-CARD-014-6.1, NBH-CARD-014-6.2, NBH-CARD-014-6.3

Each was put to the model and came back without a verdict — a gap in what we know, not a criterion ruled irrelevant. A criterion written for a service other than the one denied is recorded as not_applicable with its reason, not left out. These count against the case: the basis for appealing is tested as though every one of them were unmet.

Section 3 of 4

The letter that goes out over your name — attempt 3

Subject: Appeal of Coverage Denial for Cardiac Magnetic Resonance Imaging - Member ID: NBH-4417-20551 - Claim: CLM-2026-0519-71144

RE: Member ID NBH-4417-20551 Claim Number: CLM-2026-0519-71144 Service Denied: Magnetic resonance imaging, cardiac, with contrast material, including stress imaging and morphology To Appeals Coordinator, We are appealing the denial of coverage for cardiac magnetic resonance imaging for member NBH-4417-20551 under claim CLM-2026-0519-71144. The medical record documents that all requirements under policy section NBH-CARD-014-3 are met. 1. Documentation of Symptoms (NBH-CARD-014-3.1): Policy section NBH-CARD-014-3.1 requires documentation of symptoms consistent with cardiac disease, including dyspnoea on exertion, persisting for at least six weeks or documented as progressive. On 18 February 2026, the record documents an "Eighty-three year old woman reporting six weeks of increasing breathlessness on exertion." On 22 April 2026, the treating cardiologist documented: "Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea." 2. Initial Diagnostic Evaluation (NBH-CARD-014-3.2): Policy section NBH-CARD-014-3.2 requires completion of an initial diagnostic evaluation including a twelve-lead electrocardiogram and a transthoracic echocardiogram within the twelve months preceding the request. The record documents a "Twelve-lead electrocardiogram performed 2 March 2026" and a "Transthoracic echocardiogram performed 9 March 2026." 3. Inconclusive or Technically Inadequate Initial Evaluation (NBH-CARD-014-3.3): Policy section NBH-CARD-014-3.3 requires that the initial evaluation is inconclusive, equivocal, or technically inadequate for the clinical question posed, with documentation of what remains unresolved. On 22 April 2026, the treating cardiologist documented: "The echocardiogram is technically inadequate for the clinical question" and noted that "The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically." 4. Management Decision Depending on the Result (NBH-CARD-014-3.4): Policy section NBH-CARD-014-3.4 requires that the requested study is expected to change clinical management and that the treating clinician has documented the specific management decision that depends on the result. On 22 April 2026, the treating cardiologist documented: "the distinction determines management directly: a positive amyloid pattern would take her to bone scintigraphy and serum free light chains and, if confirmed, to disease-modifying therapy, whereas an ischaemic pattern of enhancement would take her to invasive angiography." 5. Assessment of Relative Contraindication (NBH-CARD-014-3.5): Policy section NBH-CARD-014-3.5 requires that there is no contraindication to magnetic resonance imaging, or that where a relative contraindication exists, the medical record documents that it has been addressed. On 22 April 2026, the record addresses the patient's relative contraindication, noting: "She has a permanent pacemaker; the device details will need to be confirmed with the implanting centre before scheduling." Based on the documentation satisfying each criterion of NBH-CARD-014-3, we request overturn of the denial and approval of coverage for the requested study.

Requested action: Overturn the coverage denial and approve coverage for cardiac magnetic resonance imaging with contrast material, including stress imaging and morphology.

Every factual claim the letter makes about the patient

These are the sentences you are attesting to. If one of them is not true of this patient, reject the draft rather than co-signing it.

On February 18, 2026, the patient was an eighty-three year old woman reporting six weeks of increasing breathlessness on exertion.
On April 22, 2026, the cardiologist documented that the patient's symptoms had progressed further since February, that she stopped three times on the same walk, and that she developed mild orthopnoea.
A twelve-lead electrocardiogram was performed on March 2, 2026.
A transthoracic echocardiogram was performed on March 9, 2026.
On April 22, 2026, the cardiologist documented that the echocardiogram is technically inadequate for the clinical question.
On April 22, 2026, the cardiologist documented that the differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents excluding electrocardiographically.
On April 22, 2026, the cardiologist documented that the distinction determines management directly: a positive amyloid pattern would take her to bone scintigraphy and serum free light chains and, if confirmed, to disease-modifying therapy, whereas an ischaemic pattern of enhancement would take her to invasive angiography.
On April 22, 2026, the cardiologist documented that the patient has a permanent pacemaker and that device details will need to be confirmed with the implanting centre before scheduling.

Section 4 of 4

Your co-sign

Waiting on the billing clerk and the ordering clinician. Nothing is transmitted until every required signature is present.

Not signed

Billing clerk

Confirms the paper trail: that the cited sections exist, that the quoted policy text matches its source, and that no claim outruns the matrix.

No approval recorded yet.
Not signed

Ordering clinician

Attests to the clinical argument: that the letter's account of the care and the chart is accurate. A clerk is not in a position to judge this.

No co-sign recorded yet.

Sign the clinical argument in attempt 3

Your signature is pinned to this drafting attempt. If the letter is rewritten afterwards, it does not carry your name until you sign the new one.

Your name Recorded on the case and in the audit log. Required.

Credential MD, DO, NP, PA, and so on. Required.

NPI (optional) Ten digits. Some payers reject an appeal signed without one.

Anything to add (optional) Stored on the case. Not sent to the payer.

Attestation

You are attesting to the medicine, not to the paperwork. Whether every citation resolves and every quotation matches its source is the clerk's confirmation, recorded separately.

I ordered this care, or I am authorised to sign for the clinician who did, and the clinical argument in this letter is accurate.

Recorded with your name, credential and the time, against drafting attempt 3.

If the clinical argument is wrong, do not co-sign it. Say so on the full case record, where the draft can be rejected and rewritten.