Hanover Insurance MRI Pelvis without contrast prior authorization requirements (2026)
What Hanover Insurance generally requires to approve MRI Pelvis without contrast (CPT 72195), for Auto No-Fault (NJ PIP) plans. Yes. Hanover Insurance generally requires prior authorization for MRI Pelvis without contrast (CPT 72195).
Medical-necessity criteria Hanover Insurance generally applies
Decision point review (DPR) required: MRI is on the N.J.A.C. 11:3-4.5(b) diagnostic-test list, so the determination to administer it is a decision point for ALL injuries, not just Care Path injuries (11:3-4.5(d)). Per 11:3-4.5(b)5, MRI use should conform to ACR Appropriateness Criteria and is not normally performed within 5 days of the insured event absent red flags (e.g., gross motor deficits, incontinence, acute nerve-root compression). No DPR or precertification applies to emergency care or within 10 days of the accident (11:3-4.7(b)) - medical necessity and causation still apply. Submit the DOBI Uniform APTP form with clinically supported findings from a personal examination; the carrier must respond within 3 business days (11:3-4.7(c)4), and under DOBI-approved plans treatment is deemed authorized until a determination issues if it fails to respond timely. Failure to request DPR where required risks a co-payment penalty of up to 50% of the eligible charge (11:3-4.4(e)); using a non-network facility where the plan has an approved voluntary network for MRI can add a penalty of up to 30% (11:3-4.4(g), 11:3-4.8(b)). Spine soft-tissue and disc-herniation injuries (identified injuries) also follow the DOBI Care Paths (11:3-4.6).
Commonly required documentation
- DOBI Uniform Attending Provider Treatment Plan (APTP) form ver. 16.03.10 (nj.gov/dobi/pipinfo/aptp_ver160310.pdf) - patient name/DOB, claim number, date of accident, ICD-10 codes, each CPT code with frequency/duration, provider signature
- clinically supported findings from a personal physical examination
- relevant progress notes and prior imaging/test results. Incomplete APTPs are denied as deficient.
How to submit
- Method: Fax APTP to CSG/Medlogix 856-910-2501
- Portal: CSG (Medlogix)
- Typical turnaround: about 3 days
Sources & verification
NJ PIP (auto no-fault). Sources: N.J.A.C. 11:3-4 (eff. 10/16/2017), carrier DPRP: https://sites.hanover.com/thg/pdf/nj_decision_point.pdf; OSSNJ no-fault pre-cert reference table (photographed 2026-06-25). Internal appeal required before PIP arbitration (11:3-4.7B): pre-service within 30 days of denial (decision due 14 days), post-service at least 45 days before ADR (decision due 30 days), on DOBI uniform appeal forms. IME: must be scheduled within 7 calendar days, same-discipline examiner, decision 3 business days after exam (11:3-4.7(e)). Statewide facts verified 2026-07-09. CSG contracted as Hanover's utilization review organization per plan brochure; OSSNJ table fax 856-910-2501 matches the Medlogix standard intake. [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Hanover Insurance require prior authorization for MRI Pelvis without contrast?
Yes. Hanover Insurance generally requires prior authorization for MRI Pelvis without contrast (CPT 72195).
What does Hanover Insurance require to approve MRI Pelvis without contrast?
Decision point review (DPR) required: MRI is on the N.J.A.C. 11:3-4.5(b) diagnostic-test list, so the determination to administer it is a decision point for ALL injuries, not just Care Path injuries (11:3-4.5(d)). Per 11:3-4.5(b)5, MRI use should conform to ACR Appropriateness Criteria and is not normally performed within 5 days of the insured event absent red flags (e.g., gross motor deficits, in… Always confirm against the current Hanover Insurance policy.
How long does a Hanover Insurance prior authorization take?
Hanover Insurance typically decides MRI Pelvis without contrast requests in about 3 days. Timeframes vary; check the payer portal.
Submitting MRI Pelvis without contrast to Hanover Insurance?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.