Larkspur Health Plan — Member Services
Prior Authorization PA-2026-004471
| Service | MRI KNEE W/O CONTRAST (73721) |
| Requesting provider | OKAFOR, ADAEZE MD |
| Date received | 08/12/2026 |
| Determination | DENIED — 08/17/2026 |
| Reason | See attached determination letter |
Documents
How to file an appeal
- Download and print Form LHP-402 — Member Appeal Request (6 pages).
- Complete all sections in blue or black ink. Incomplete forms will be returned.
- Attach copies of supporting medical documentation. Do not send originals.
- Mail to: Member Appeals, P.O. Box 41120, Portland, OR 97240
or fax to: 1-800-555-0147 - Allow up to 7 calendar days from receipt for a standard appeal decision. Expedited appeals require a physician certification (Section 5 of the form).
Appeals cannot be submitted through this website at this time.
This is the deliberately typical “before” version of the portal: no site tools, PDF letters, and a fax number. Everything here is fictional.