AUT-2026-00188

Stress Echocardiogram with imaging

Roberto Mendoza · 54M · UHC · UnitedHealthcare Choice Plus

In review

Patient

NameRoberto Mendoza

DOBSep 30, 1971 · age 54

MRNMRN-009447

Member IDUHC-947213556

StateTX

PlanUnitedHealthcare Choice Plus

Ordering provider

NameMarcos Garcia, MD

NPI1922088901

SpecialtyCardiology

OrganizationPacific Heart Specialists

Order

CPT

93351

ICD-10

R07.9Z82.49E78.5

Service dateMay 12, 2026

FacilityPacific Heart Outpatient Lab

UrgencyRoutine

Est. cost$940

Clinical narrative

54M with new exertional chest pressure x 3 weeks. Resolves with rest within 5 minutes. Family history: father MI age 58, brother CABG age 55. LDL 162. Diamond-Forrester intermediate pre-test probability. Resting EKG shows LBBB — uninterpretable for ischemia. No prior stress imaging.

Evidence: 5 source documents

·Cardiology Consult 2026-05-04 — Dr. Garcia
·EKG Report 2026-05-04
·Imaging/Cardiology History query
·Order ServiceRequest 2026-05-08

Criteria evaluation

UHC Medical Policy CARD.0014

Stress Echocardiography

4 met · 1 partial · 0 missing · 5 total

Symptoms suggestive of CAD OR risk stratification indication

Met

“Exertional chest pressure x 3 weeks, relieved by rest within 5 min. Onset with stair climbing.”

Cardiology Consult 2026-05-04 — Dr. Garcia · p.1

confidence 0.96

Citation: ACC/AHA Appropriate Use Criteria 2024

Intermediate or high pre-test probability

Met

“Diamond-Forrester intermediate pre-test probability based on age, sex, symptom characteristics.”

Cardiology Consult 2026-05-04 — Dr. Garcia · p.2

confidence 0.91

Citation: UHC CARD.0014 §III.B

Resting EKG uninterpretable OR exercise capacity limited

Met

“Resting 12-lead EKG: LBBB. Uninterpretable for ischemic changes during exercise alone.”

EKG Report 2026-05-04 · p.1

confidence 0.99

Citation: ACC/AHA AUC 2024 §6.2

No equivalent stress test within 12 months

Met

“No prior stress test of any modality on record.”

Imaging/Cardiology History query

confidence 1.00

Citation: UHC CARD.0014 §III.D

Ordered by cardiology OR PCP with documented evaluation

Partial

“Order signed by Dr. Garcia, cardiology. Requesting copy of full H&P with documented vitals — chart shows H&P in transit from referring PCP.”

Order ServiceRequest 2026-05-08

confidence 0.55

Citation: UHC CARD.0014 §II

Ready to submit

Submit to UHC

Authora will package a Da Vinci PAS request bundle, transmit to UnitedHealthcare, and deliver the X12 278 response back into this case.

· 1 CPT code(s), 3 diagnosis code(s)
· 5 evidence elements attached
· Policy: UHC Medical Policy CARD.0014

Submission timeline

2h agoPayer
UHC UM Nurse: requesting full H&P from referring PCP
UHC
10h agoPayer
UHC acknowledged receipt
UHC
11h agoSystem
Submitted to UHC — partial documentation flagged
11h agoAI
4 of 5 criteria fully met; criterion 5 needs supporting H&P
11h agoProvider
Case opened from cardiology consult
Dr. Garcia
11h agoAI
5 evidence elements extracted, 1 partial
Authora

Wire format

{
  "resourceType": "Bundle",
  "id": "pas-request-AUT-2026-00188",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"
    ]
  },
  "type": "collection",
  "timestamp": "2026-05-31T21:43:49.679Z",
  "entry": [
    {
      "fullUrl": "urn:uuid:6e312104-f0ff-457a-b2f7-858d3ba7f6a1",
      "resource": {
        "resourceType": "Claim",
        "id": "6e312104-f0ff-457a-b2f7-858d3ba7f6a1",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
          ]
        },
        "identifier": [
          {
            "system": "https://authora.health/cases",
            "value": "AUT-2026-00188"
          }
        ],
        "status": "active",
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/claim-type",
              "code": "institutional"
            }
          ]
        },
        "use": "preauthorization",
        "patient": {
          "reference": "urn:uuid:72f06191-d9b1-4b0a-9497-aca4acc71a7f"
        },
        "created": "2026-05-08T03:30:00.000Z",
        "insurer": {
          "reference": "urn:uuid:b08c6f9c-9979-4a64-99a1-714a402718af"
        },
        "provider": {
          "reference": "urn:uuid:7e66cbaa-a821-40a5-a926-31beccd6835e"
        },
        "priority": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/processpriority",
              "code": "normal"
            }
          ]
        },
        "careTeam": [
          {
            "sequence": 1,
            "provider": {
              "reference": "urn:uuid:55b4a484-0950-4db4-a403-39735daea1a4"
            },
            "role": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
                  "code": "primary"
                }
              ]
            }
          }
        ],
        "diagnosis": [
          {
            "sequence": 1,
            "diagnosisCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/sid/icd-10-cm",
                  "code": "R07.9",
                  "display": "Chest pain, unspecified"
                }
              ]
            }
          },
          {
            "sequence": 2,
            "diagnosisCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/sid/icd-10-cm",
                  "code": "Z82.49",
                  "display": "Family history of ischemic heart disease"
                }
              ]
            }
          },
          {
            "sequence": 3,
            "diagnosisCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/sid/icd-10-cm",
                  "code": "E78.5",
                  "display": "Hyperlipidemia, unspecified"
                }
              ]
            }
          }
        ],
        "insurance": [
          {
            "sequence": 1,
            "focal": true,
            "coverage": {
              "reference": "urn:uuid:d80efb45-3f64-4953-85c8-9baa8ab9b614"
            }
          }
        ],
        "item": [
          {
            "sequence": 1,
            "careTeamSequence": [
              1
            ],
            "diagnosisSequence": [
              1,
              2,
              3
            ],
            "productOrService": {
              "coding": [
                {
                  "system": "http://www.ama-assn.org/go/cpt",
                  "code": "93351",
                  "display": "Stress echo with continuous ECG, exercise"
                }
              ]
            },
            "servicedDate": "2026-05-12",
            "extension": [
              {
                "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail",
                "valueCodeableConcept": {
                  "coding": [
                    {
                      "system": "https://codesystem.x12.org/005010/1525",
                      "code": "SC",
                      "display": "Specialty Care Review"
                    }
                  ]
                }
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:72f06191-d9b1-4b0a-9497-aca4acc71a7f",
      "resource": {
        "resourceType": "Patient",
        "id": "72f06191-d9b1-4b0a-9497-aca4acc71a7f",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-mbi",
            "value": "UHC-947213556"
          },
          {
            "system": "https://authora.health/mrn",
            "value": "MRN-009447"
          }
        ],
        "name": [
          {
            "family": "Mendoza",
            "given": [
              "Roberto"
            ]
          }
        ],
        "gender": "male",
        "birthDate": "1971-09-30",
        "address": [
          {
            "state": "TX",
            "country": "US"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:d80efb45-3f64-4953-85c8-9baa8ab9b614",
      "resource": {
        "resourceType": "Coverage",
        "id": "d80efb45-3f64-4953-85c8-9baa8ab9b614",
        "status": "active",
        "subscriberId": "UHC-947213556",
        "beneficiary": {
          "reference": "urn:uuid:72f06191-d9b1-4b0a-9497-aca4acc71a7f"
        },
        "payor": [
          {
            "reference": "urn:uuid:b08c6f9c-9979-4a64-99a1-714a402718af"
          }
        ],
        "class": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "plan"
                }
              ]
            },
            "value": "UnitedHealthcare Choice Plus"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:b08c6f9c-9979-4a64-99a1-714a402718af",
      "resource": {
        "resourceType": "Organization",
        "id": "b08c6f9c-9979-4a64-99a1-714a402718af",
        "identifier": [
          {
            "system": "https://hl7.org/fhir/sid/us-payer",
            "value": "uhc"
          }
        ],
        "name": "UnitedHealthcare",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/organization-type",
                "code": "ins"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:7e66cbaa-a821-40a5-a926-31beccd6835e",
      "resource": {
        "resourceType": "Organization",
        "id": "7e66cbaa-a821-40a5-a926-31beccd6835e",
        "name": "Pacific Heart Specialists",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/organization-type",
                "code": "prov"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:55b4a484-0950-4db4-a403-39735daea1a4",
      "resource": {
        "resourceType": "Practitioner",
        "id": "55b4a484-0950-4db4-a403-39735daea1a4",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-npi",
            "value": "1922088901"
          }
        ],
        "name": [
          {
            "family": "Garcia",
            "given": [
              "Marcos"
            ],
            "suffix": [
              "MD"
            ]
          }
        ]
      }
    }
  ]
}

Payer connection

UnitedHealthcare

PARDD live

CRD

DTR

PAS

Agent trace · run run_aut-2026-00188_94109

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 duration2.86s

Agents6

Total tokens5,279 in · 2,367 out

Total cost$0.1415

01Patient Context486ms·499 / 264 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·177ms03:30:00.000

›Input

{
  "resourceType": "Patient",
  "identifier": "MRN-009447"
}

›Output

{
  "id": "pt-mendoza",
  "name": "Mendoza, Roberto",
  "birthDate": "1971-09-30",
  "gender": "male",
  "address": {
    "state": "TX",
    "country": "US"
  }
}

fhir.search_coverage·122ms03:30:00.177

›Input

{
  "patient": "pt-mendoza",
  "status": "active"
}

›Output

{
  "coverage": {
    "id": "cov-pt-mendoza",
    "payor": "UnitedHealthcare",
    "plan": "UnitedHealthcare Choice Plus",
    "subscriberId": "UHC-947213556",
    "status": "active"
  }
}

fhir.search_encounter·187ms03:30:00.299

›Input

{
  "patient": "pt-mendoza",
  "_count": 5,
  "_sort": "-date"
}

›Output

{
  "encounters": [
    {
      "id": "enc-symptoms",
      "type": "AMB",
      "source": "Cardiology Consult 2026-05-04 — Dr. Garcia"
    },
    {
      "id": "enc-intermediate_risk",
      "type": "AMB",
      "source": "Cardiology Consult 2026-05-04 — Dr. Garcia"
    },
    {
      "id": "enc-ekg_uninterpretable",
      "type": "AMB",
      "source": "EKG Report 2026-05-04"
    },
    {
      "id": "enc-no_recent",
      "type": "AMB",
      "source": "Imaging/Cardiology History query"
    }
  ]
}

Output

{
  "patientId": "pt-mendoza",
  "coverageId": "cov-pt-mendoza",
  "recentEncounterCount": 4,
  "ageAtService": 54
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pcx-2.4.1

Statuscompleted

02Policy Match297ms·370 / 203 tok·$0.0011

Thinking

Single high-confidence match: Stress Echocardiography. 5 criteria current as of 2026-02-01.

Tool calls (2)

policy_index.lookup·112ms03:30:00.486

›Input

{
  "payerId": "uhc",
  "cpt": "93351",
  "plan": "UnitedHealthcare Choice Plus"
}

›Output

{
  "policyId": "uhc-stress-echo-2026",
  "citation": "UHC Medical Policy CARD.0014",
  "effectiveDate": "2026-01-01"
}

policy_index.fetch_criteria·185ms03:30:00.598

›Input

{
  "policyId": "uhc-stress-echo-2026",
  "version": "2026-02-01"
}

›Output

{
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "symptoms",
      "label": "Symptoms suggestive of CAD OR risk stratification indication",
      "source": "ACC"
    },
    {
      "id": "intermediate_risk",
      "label": "Intermediate or high pre-test probability",
      "source": "ACC"
    },
    {
      "id": "ekg_uninterpretable",
      "label": "Resting EKG uninterpretable OR exercise capacity limited",
      "source": "ACC"
    },
    {
      "id": "no_recent",
      "label": "No equivalent stress test within 12 months",
      "source": "PayerPolicy"
    },
    {
      "id": "ordered_by_cardiology",
      "label": "Ordered by cardiology OR PCP with documented evaluation",
      "source": "PayerPolicy"
    }
  ]
}

Output

{
  "policyId": "uhc-stress-echo-2026",
  "criteriaCount": 5
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pmt-3.1.0

Statuscompleted

03Evidence Extraction540ms·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=4, partial=1, missing=0.

Tool calls (5)

chart.extract_evidence·502ms03:30:00.805

›Input

{
  "criterion_id": "symptoms",
  "criterion_label": "Symptoms suggestive of CAD OR risk stratification indication",
  "policy_citation": "ACC/AHA Appropriate Use Criteria 2024",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "symptoms",
  "status": "met",
  "excerpt": "Exertional chest pressure x 3 weeks, relieved by rest within 5 min. Onset with stair climbing.",
  "sourceDocument": "Cardiology Consult 2026-05-04 — Dr. Garcia",
  "confidence": 0.96
}

chart.extract_evidence·498ms03:30:00.798

›Input

{
  "criterion_id": "intermediate_risk",
  "criterion_label": "Intermediate or high pre-test probability",
  "policy_citation": "UHC CARD.0014 §III.B",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "intermediate_risk",
  "status": "met",
  "excerpt": "Diamond-Forrester intermediate pre-test probability based on age, sex, symptom characteristics.",
  "sourceDocument": "Cardiology Consult 2026-05-04 — Dr. Garcia",
  "confidence": 0.91
}

chart.extract_evidence·455ms03:30:00.795

›Input

{
  "criterion_id": "ekg_uninterpretable",
  "criterion_label": "Resting EKG uninterpretable OR exercise capacity limited",
  "policy_citation": "ACC/AHA AUC 2024 §6.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "ekg_uninterpretable",
  "status": "met",
  "excerpt": "Resting 12-lead EKG: LBBB. Uninterpretable for ischemic changes during exercise alone.",
  "sourceDocument": "EKG Report 2026-05-04",
  "confidence": 0.99
}

chart.extract_evidence·352ms03:30:00.787

›Input

{
  "criterion_id": "no_recent",
  "criterion_label": "No equivalent stress test within 12 months",
  "policy_citation": "UHC CARD.0014 §III.D",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "no_recent",
  "status": "met",
  "excerpt": "No prior stress test of any modality on record.",
  "sourceDocument": "Imaging/Cardiology History query",
  "confidence": 1
}

chart.extract_evidence·488ms03:30:00.835

›Input

{
  "criterion_id": "ordered_by_cardiology",
  "criterion_label": "Ordered by cardiology OR PCP with documented evaluation",
  "policy_citation": "UHC CARD.0014 §II",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "ordered_by_cardiology",
  "status": "partial",
  "excerpt": "Order signed by Dr. Garcia, cardiology. Requesting copy of full H&P with documented vitals — chart shows H&P in transit from referring PCP.",
  "sourceDocument": "Order ServiceRequest 2026-05-08",
  "confidence": 0.55
}

Output

{
  "metCount": 4,
  "partialCount": 1,
  "missingCount": 0,
  "avgConfidence": 0.882
}

Notes

·1 criterion partially evidenced — chart extraction suggests resubmittable with one additional artifact.

Modelclaude-opus-4-7@20260318

Promptauthora-evx-4.7.2

Statuscompleted

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·57ms03:30:01.323
›Input
{ "urgency": "routine", "slaWindowHours": 168, "payerId": "uhc" }
›Output
{ "compliant": true, "marginHours": 164 }
compliance.check_denial_reason_specificity·47ms03:30:01.380
›Input
{ "policyId": "uhc-stress-echo-2026" }
›Output
{ "specificityScore": 1, "requiredFieldsCovered": [ "criterionRef", "evidenceGap", "remediation", "appealPath" ] }
compliance.public_reporting_fields·40ms03:30:01.427
›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

05Submission1.14s·720 / 360 tok·$0.0020

Thinking

Bundle profile-validated. Transmission acknowledged by UHC. 278/13 response parsed (HCR01=A4).

Tool calls (3)

fhir.build_pas_bundle·176ms03:30:01.467

›Input

{
  "caseNumber": "AUT-2026-00188",
  "profile": "davinci-pas-2.1",
  "validate": true
}

›Output

{
  "bundleId": "pas-request-AUT-2026-00188",
  "profileConformance": "valid",
  "entryCount": 6
}

payer.transmit·870ms03:30:01.643

›Input

{
  "endpoint": "https://developer.uhc.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00188"
}

›Output

{
  "ack": "received",
  "correlationId": "UHC-704881"
}

x12.parse_278_response·98ms03:30:02.513

›Input

{
  "format": "005010X216",
  "correlationId": "UHC-704881"
}

›Output

{
  "hcr01": "A4",
  "authPeriod": {}
}

Output

{
  "bundleId": "pas-request-AUT-2026-00188",
  "hcr01": "A4",
  "authNumber": null
}

Modelclaude-haiku-4-5@20251001

Promptauthora-sub-2.2.0

Statuscompleted

06Notification253ms·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·153ms03:30:02.611

›Input

{
  "caseNumber": "AUT-2026-00188",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}

›Output

{
  "message": "Hi Roberto — your Stress Echocardiogram with imaging request is moving through review. We'll text again as soon as there's an update.",
  "length": 138,
  "channel": "sms"
}

ehr.draft_inbasket_message·100ms03:30:02.764

›Input

{
  "caseNumber": "AUT-2026-00188",
  "recipientNpi": "1922088901",
  "urgency": "routine"
}

›Output

{
  "recipient": "Dr. Garcia",
  "subject": "PA submitted to payer",
  "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