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AUT-2026-00187

MRI Lumbar Spine without contrast

Min-Jee Park · 64F · Anthem · Anthem PPO Gold

Auto-approvedPrint authorization letter
Patient
NameMin-Jee Park
DOBApr 12, 1962 · age 64
MRNMRN-008814
Member IDANTH-W123456789
StateCA
PlanAnthem PPO Gold
Ordering provider
NameChinedu Okonkwo, MD
NPI1689345712
SpecialtyInternal Medicine
OrganizationOakwood Primary Care
Order
CPT
72148
ICD-10
M54.50M51.36M54.16
Service dateMay 10, 2026
FacilityBay Imaging Center — Daly City
UrgencyRoutine
Est. cost$1,180
Clinical narrative
64F with 8 weeks of progressive low back pain radiating to right lateral leg. Failed 6 weeks of supervised PT (3x/week) and a full NSAID course (meloxicam 15mg daily). Exam: positive straight leg raise on right at 45°, decreased sensation L5 distribution, 4/5 strength right EHL. Last MRI lumbar spine 2022 (3.5 years prior). PCP requesting MRI to evaluate suspected L4-L5 disc herniation prior to spine consultation.
Evidence: 5 source documents
  • ·Progress Note 2026-04-10 — Dr. Okonkwo
  • ·PT Discharge Summary 2026-04-08 — Bay Physical Therapy
  • ·Imaging History — EHR ad-hoc query
  • ·NPPES verification
Criteria evaluation
Anthem Medical Policy RAD.00029

Magnetic Resonance Imaging — Lumbar Spine

5 met · 0 partial · 0 missing · 5 total
Symptom duration ≥6 weeks OR red-flag symptoms present
Met
“Symptoms began 8 weeks ago, progressive in severity. Patient reports right lateral leg pain.”
Progress Note 2026-04-10 — Dr. Okonkwo · p.1
confidence 0.97
Citation: Anthem RAD.00029 §III.A.1
Failed conservative therapy (unless red flags)
Met
“Completed 6 weeks supervised PT (3x weekly, 18 sessions documented). Meloxicam 15mg daily x 6 weeks with partial relief only.”
PT Discharge Summary 2026-04-08 — Bay Physical Therapy · p.1
confidence 0.99
Citation: Anthem RAD.00029 §III.A.2
Focal neuro findings on exam OR surgical/injection planning
Met
“Positive SLR right at 45°. Decreased sensation L5 dermatome. Right EHL 4/5. DTR 1+ ankle bilaterally.”
Progress Note 2026-04-10 — Dr. Okonkwo · p.2
confidence 0.95
Citation: Anthem RAD.00029 §III.A.3
No equivalent imaging within 12 months
Met
“Last lumbar MRI 2022-11-14 (~3.5 years prior). No imaging in last 12 months.”
Imaging History — EHR ad-hoc query
confidence 1.00
Citation: Anthem RAD.00029 §III.A.4
Ordered by credentialed provider
Met
“Dr. Chinedu Okonkwo, MD — NPI 1689345712 — active CA license A123456 — Internal Medicine.”
NPPES verification
confidence 1.00
Citation: Anthem RAD.00029 §II
Decision
Auto-approved
Auth #ANTH-2026-887766 · May 8, 2026 → Aug 8, 2026
Symptom duration ≥6 weeks (✓), failed conservative therapy with PT + NSAIDs (✓), focal neuro exam findings consistent with L5 radiculopathy (✓), no recent equivalent imaging (✓), credentialed PCP order (✓). Determination meets all elements of Anthem RAD.00029. Auto-approval issued under policy; member entitled to 90-day authorization window.
Decided by Authora decision engine23 min ago
Agent trace · run run_aut-2026-00187_96564

Pipeline execution

Six agents evaluated this request. Every tool call below has the exact input and output observed in the run, with model version, prompt version, latency, and cost.

Replay this run
Total duration2.84s
Agents6
Total tokens5,292 in · 2,347 out
Total cost$0.1414
  1. 01Patient Context530ms·553 / 258 tok·$0.0015
    Thinking
    Patient on active commercial coverage. Recent encounters cover the relevant clinical window. Demographics consistent with order.
    Tool calls (3)
    fhir.read_patient·211ms14:06:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-008814"
}
    ›Output 
    {
  "id": "pt-park",
  "name": "Park, Min-Jee",
  "birthDate": "1962-04-12",
  "gender": "female",
  "address": {
    "state": "CA",
    "country": "US"
  }
}
    fhir.search_coverage·133ms14:06:00.211
    ›Input
    {
  "patient": "pt-park",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-park",
    "payor": "Anthem (Elevance Health)",
    "plan": "Anthem PPO Gold",
    "subscriberId": "ANTH-W123456789",
    "status": "active"
  }
}
    fhir.search_encounter·186ms14:06:00.344
    ›Input
    {
  "patient": "pt-park",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-duration",
      "type": "AMB",
      "source": "Progress Note 2026-04-10 — Dr. Okonkwo"
    },
    {
      "id": "enc-conservative_care",
      "type": "AMB",
      "source": "PT Discharge Summary 2026-04-08 — Bay Physical Therapy"
    },
    {
      "id": "enc-exam_findings",
      "type": "AMB",
      "source": "Progress Note 2026-04-10 — Dr. Okonkwo"
    },
    {
      "id": "enc-no_recent_imaging",
      "type": "AMB",
      "source": "Imaging History — EHR ad-hoc query"
    }
  ]
}
    Output
    {
  "patientId": "pt-park",
  "coverageId": "cov-pt-park",
  "recentEncounterCount": 4,
  "ageAtService": 64
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match216ms·329 / 189 tok·$0.0010
    Thinking
    Single high-confidence match: Magnetic Resonance Imaging — Lumbar Spine. 5 criteria current as of 2026-03-15.
    Tool calls (2)
    policy_index.lookup·86ms14:06:00.530
    ›Input
    {
  "payerId": "anthem",
  "cpt": "72148",
  "plan": "Anthem PPO Gold"
}
    ›Output 
    {
  "policyId": "anthem-lumbar-mri-2026",
  "citation": "Anthem Medical Policy RAD.00029",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·130ms14:06:00.616
    ›Input
    {
  "policyId": "anthem-lumbar-mri-2026",
  "version": "2026-03-15"
}
    ›Output 
    {
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "duration",
      "label": "Symptom duration ≥6 weeks OR red-flag symptoms present",
      "source": "PayerPolicy"
    },
    {
      "id": "conservative_care",
      "label": "Failed conservative therapy (unless red flags)",
      "source": "PayerPolicy"
    },
    {
      "id": "exam_findings",
      "label": "Focal neuro findings on exam OR surgical/injection planning",
      "source": "PayerPolicy"
    },
    {
      "id": "no_recent_imaging",
      "label": "No equivalent imaging within 12 months",
      "source": "PayerPolicy"
    },
    {
      "id": "ordered_by_credentialed",
      "label": "Ordered by credentialed provider",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "anthem-lumbar-mri-2026",
  "criteriaCount": 5
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction534ms·2,900 / 1,220 tok·$0.1350
    Thinking
    Fanned out 5 parallel extract_evidence calls against chart resources. Each criterion returns a quoted excerpt with source provenance and a confidence score. Met=5, partial=0, missing=0.
    Tool calls (5)
    chart.extract_evidence·374ms14:06:00.804
    ›Input
    {
  "criterion_id": "duration",
  "criterion_label": "Symptom duration ≥6 weeks OR red-flag symptoms present",
  "policy_citation": "Anthem RAD.00029 §III.A.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "duration",
  "status": "met",
  "excerpt": "Symptoms began 8 weeks ago, progressive in severity. Patient reports right lateral leg pain.",
  "sourceDocument": "Progress Note 2026-04-10 — Dr. Okonkwo",
  "confidence": 0.97
}
    chart.extract_evidence·475ms14:06:00.805
    ›Input
    {
  "criterion_id": "conservative_care",
  "criterion_label": "Failed conservative therapy (unless red flags)",
  "policy_citation": "Anthem RAD.00029 §III.A.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "conservative_care",
  "status": "met",
  "excerpt": "Completed 6 weeks supervised PT (3x weekly, 18 sessions documented). Meloxicam 15mg daily x 6 weeks with partial relief only.",
  "sourceDocument": "PT Discharge Summary 2026-04-08 — Bay Physical Therapy",
  "confidence": 0.99
}
    chart.extract_evidence·428ms14:06:00.773
    ›Input
    {
  "criterion_id": "exam_findings",
  "criterion_label": "Focal neuro findings on exam OR surgical/injection planning",
  "policy_citation": "Anthem RAD.00029 §III.A.3",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "exam_findings",
  "status": "met",
  "excerpt": "Positive SLR right at 45°. Decreased sensation L5 dermatome. Right EHL 4/5. DTR 1+ ankle bilaterally.",
  "sourceDocument": "Progress Note 2026-04-10 — Dr. Okonkwo",
  "confidence": 0.95
}
    chart.extract_evidence·430ms14:06:00.760
    ›Input
    {
  "criterion_id": "no_recent_imaging",
  "criterion_label": "No equivalent imaging within 12 months",
  "policy_citation": "Anthem RAD.00029 §III.A.4",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_recent_imaging",
  "status": "met",
  "excerpt": "Last lumbar MRI 2022-11-14 (~3.5 years prior). No imaging in last 12 months.",
  "sourceDocument": "Imaging History — EHR ad-hoc query",
  "confidence": 1
}
    chart.extract_evidence·435ms14:06:00.748
    ›Input
    {
  "criterion_id": "ordered_by_credentialed",
  "criterion_label": "Ordered by credentialed provider",
  "policy_citation": "Anthem RAD.00029 §II",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "ordered_by_credentialed",
  "status": "met",
  "excerpt": "Dr. Chinedu Okonkwo, MD — NPI 1689345712 — active CA license A123456 — Internal Medicine.",
  "sourceDocument": "NPPES verification",
  "confidence": 1
}
    Output
    {
  "metCount": 5,
  "partialCount": 0,
  "missingCount": 0,
  "avgConfidence": 0.982
}
    Modelclaude-opus-4-7@20260318
    Promptauthora-evx-4.7.2
    Statuscompleted
  4. 04CMS-0057-F Compliance144ms·380 / 140 tok·$0.0009
    Thinking
    7-day standard window validated. Denial-reason fields covered. 18/18 public-reporting fields populated.
    Tool calls (3)
    compliance.evaluate_sla·58ms14:06:01.280
    ›Input
    {
  "urgency": "routine",
  "slaWindowHours": 168,
  "payerId": "anthem"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 164
}
    compliance.check_denial_reason_specificity·41ms14:06:01.338
    ›Input
    {
  "policyId": "anthem-lumbar-mri-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·45ms14:06:01.379
    ›Input
    {
  "quarter": "2026Q2"
}
    ›Output 
    {
  "fieldsCovered": 18,
  "fieldsRequired": 18,
  "attestation": "ready"
}
    Output
    {
  "sla": "compliant",
  "denialSpecificity": 1,
  "publicReporting": "ready"
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-cmp-1.6.0
    Statuscompleted
  5. 05Submission1.15s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by Anthem. 278/13 response parsed (HCR01=A1).
    Tool calls (3)
    fhir.build_pas_bundle·181ms14:06:01.424
    ›Input
    {
  "caseNumber": "AUT-2026-00187",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00187",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·852ms14:06:01.605
    ›Input
    {
  "endpoint": "https://api.anthem.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00187"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "ANTHEM-521250"
}
    x12.parse_278_response·116ms14:06:02.457
    ›Input
    {
  "format": "005010X216",
  "correlationId": "ANTHEM-521250"
}
    ›Output 
    {
  "hcr01": "A1",
  "authNumber": "ANTH-2026-887766",
  "authPeriod": {
    "start": "2026-05-08",
    "end": "2026-08-08"
  }
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00187",
  "hcr01": "A1",
  "authNumber": "ANTH-2026-887766"
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-sub-2.2.0
    Statuscompleted
  6. 06Notification266ms·410 / 180 tok·$0.0010
    Thinking
    Patient SMS drafted at grade-8 reading level. Provider in-basket message routed to Epic queue.
    Tool calls (2)
    patient.draft_sms·152ms14:06:02.573
    ›Input
    {
  "caseNumber": "AUT-2026-00187",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi Min-Jee — your MRI Lumbar Spine without contrast has been approved. The imaging center will reach out to schedule.",
  "length": 132,
  "channel": "sms"
}
    ehr.draft_inbasket_message·114ms14:06:02.725
    ›Input
    {
  "caseNumber": "AUT-2026-00187",
  "recipientNpi": "1689345712",
  "urgency": "routine"
}
    ›Output 
    {
  "recipient": "Dr. Okonkwo",
  "subject": "PA approved",
  "body_chars": 244
}
    Output
    {
  "patientNotified": true,
  "providerNotified": true
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-not-1.4.0
    Statuscompleted
This run conforms to
Da Vinci PAS 2.1Da Vinci CRD STU2CMS-0057-FX12 005010X217/X216