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AUT-2026-00189

Pembrolizumab 200mg IV q3w — Cycle 7 (continuation)

Margaret Reilly · 68F · Aetna · Aetna Open Access Plus

ApprovedPrint authorization letter
Patient
NameMargaret Reilly
DOBFeb 14, 1958 · age 68
MRNMRN-010221
Member IDAET-554782119
StateMA
PlanAetna Open Access Plus
Ordering provider
NameWei Zhang, MD
NPI1538196274
SpecialtyMedical Oncology
OrganizationMission Cancer Center
Order
CPT
9641396415
ICD-10
C34.91Z51.81
Service dateMay 13, 2026
FacilityMission Cancer Center Infusion Suite
UrgencyRoutine
Est. cost$13,700
Clinical narrative
68F with stage IIIA NSCLC (PD-L1 TPS 65%) on cycle 7 of pembrolizumab maintenance after concurrent chemoradiation. ECOG 1. Last imaging stable. No grade ≥3 immune toxicity. NCCN-pathway aligned.
Evidence: 5 source documents
  • ·Tumor Board Note 2026-04-30
  • ·Pathology Addendum 2026-01-22
  • ·Oncology Treatment Plan 2026-02-10
  • ·Progress Note 2026-04-30 — Dr. Zhang
  • ·Toxicity Review 2026-04-30 — Dr. Zhang
Criteria evaluation
Aetna Clinical Policy Bulletin 0890

Pembrolizumab (KEYTRUDA) Continuation Therapy

5 met · 0 partial · 0 missing · 5 total
FDA-approved or NCCN-listed indication with matching disease
Met
“Stage IIIA NSCLC, post-CRT consolidation per NCCN NSCL-1.0 (2026 v1).”
Tumor Board Note 2026-04-30
confidence 0.98
Citation: NCCN Compendium 2026
Required biomarker confirmed
Met
“PD-L1 TPS 65% (22C3 assay). Lab report 2026-01-22.”
Pathology Addendum 2026-01-22
confidence 1.00
Citation: NCCN + FDA label
Appropriate line of therapy
Met
“Maintenance after concurrent chemoradiation; line of therapy aligned with NSCL-7.”
Oncology Treatment Plan 2026-02-10
confidence 0.96
Citation: NCCN guideline-specific
ECOG performance status documented (typically 0–2)
Met
“ECOG performance status: 1 (assessed 2026-04-30).”
Progress Note 2026-04-30 — Dr. Zhang
confidence 0.99
Citation: Aetna CPB 0890 §III.C
No grade ≥3 immune-related adverse event prompting discontinuation
Met
“No grade ≥3 immune-related AE on review of last 6 cycles. CTCAE assessment normal.”
Toxicity Review 2026-04-30 — Dr. Zhang
confidence 0.94
Citation: Aetna CPB 0890 §III.D
Decision
Approved
Auth #AET-2026-44009 · May 9, 2026 → Nov 9, 2026
NCCN-pathway aligned, biomarker confirmed, performance status stable, no toxicity barriers.
Decided by S. Patel, RN · UM nurse20h ago
Agent trace · run run_aut-2026-00189_83714

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 duration2.87s
Agents6
Total tokens5,267 in · 2,345 out
Total cost$0.1414
  1. 01Patient Context578ms·508 / 245 tok·$0.0014
    Thinking
    Patient on active commercial coverage. Recent encounters cover the relevant clinical window. Demographics consistent with order.
    Tool calls (3)
    fhir.read_patient·205ms10:30:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-010221"
}
    ›Output 
    {
  "id": "pt-reilly",
  "name": "Reilly, Margaret",
  "birthDate": "1958-02-14",
  "gender": "female",
  "address": {
    "state": "MA",
    "country": "US"
  }
}
    fhir.search_coverage·163ms10:30:00.205
    ›Input
    {
  "patient": "pt-reilly",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-reilly",
    "payor": "Aetna (CVS Health)",
    "plan": "Aetna Open Access Plus",
    "subscriberId": "AET-554782119",
    "status": "active"
  }
}
    fhir.search_encounter·210ms10:30:00.368
    ›Input
    {
  "patient": "pt-reilly",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-fda_indication",
      "type": "AMB",
      "source": "Tumor Board Note 2026-04-30"
    },
    {
      "id": "enc-biomarker",
      "type": "AMB",
      "source": "Pathology Addendum 2026-01-22"
    },
    {
      "id": "enc-line_of_therapy",
      "type": "AMB",
      "source": "Oncology Treatment Plan 2026-02-10"
    },
    {
      "id": "enc-ecog",
      "type": "AMB",
      "source": "Progress Note 2026-04-30 — Dr. Zhang"
    }
  ]
}
    Output
    {
  "patientId": "pt-reilly",
  "coverageId": "cov-pt-reilly",
  "recentEncounterCount": 4,
  "ageAtService": 68
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match235ms·349 / 200 tok·$0.0011
    Thinking
    Single high-confidence match: Pembrolizumab (KEYTRUDA) Continuation Therapy. 5 criteria current as of 2026-03-01.
    Tool calls (2)
    policy_index.lookup·88ms10:30:00.578
    ›Input
    {
  "payerId": "aetna",
  "cpt": "96413",
  "plan": "Aetna Open Access Plus"
}
    ›Output 
    {
  "policyId": "aetna-pembrolizumab-2026",
  "citation": "Aetna Clinical Policy Bulletin 0890",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·147ms10:30:00.666
    ›Input
    {
  "policyId": "aetna-pembrolizumab-2026",
  "version": "2026-03-01"
}
    ›Output 
    {
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "fda_indication",
      "label": "FDA-approved or NCCN-listed indication with matching disease",
      "source": "NCCN"
    },
    {
      "id": "biomarker",
      "label": "Required biomarker confirmed",
      "source": "NCCN"
    },
    {
      "id": "line_of_therapy",
      "label": "Appropriate line of therapy",
      "source": "NCCN"
    },
    {
      "id": "ecog",
      "label": "ECOG performance status documented (typically 0–2)",
      "source": "PayerPolicy"
    },
    {
      "id": "no_irae",
      "label": "No grade ≥3 immune-related adverse event prompting discontinuation",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "aetna-pembrolizumab-2026",
  "criteriaCount": 5
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction579ms·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·523ms10:30:00.869
    ›Input
    {
  "criterion_id": "fda_indication",
  "criterion_label": "FDA-approved or NCCN-listed indication with matching disease",
  "policy_citation": "NCCN Compendium 2026",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "fda_indication",
  "status": "met",
  "excerpt": "Stage IIIA NSCLC, post-CRT consolidation per NCCN NSCL-1.0 (2026 v1).",
  "sourceDocument": "Tumor Board Note 2026-04-30",
  "confidence": 0.98
}
    chart.extract_evidence·403ms10:30:00.813
    ›Input
    {
  "criterion_id": "biomarker",
  "criterion_label": "Required biomarker confirmed",
  "policy_citation": "NCCN + FDA label",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "biomarker",
  "status": "met",
  "excerpt": "PD-L1 TPS 65% (22C3 assay). Lab report 2026-01-22.",
  "sourceDocument": "Pathology Addendum 2026-01-22",
  "confidence": 1
}
    chart.extract_evidence·469ms10:30:00.860
    ›Input
    {
  "criterion_id": "line_of_therapy",
  "criterion_label": "Appropriate line of therapy",
  "policy_citation": "NCCN guideline-specific",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "line_of_therapy",
  "status": "met",
  "excerpt": "Maintenance after concurrent chemoradiation; line of therapy aligned with NSCL-7.",
  "sourceDocument": "Oncology Treatment Plan 2026-02-10",
  "confidence": 0.96
}
    chart.extract_evidence·515ms10:30:00.866
    ›Input
    {
  "criterion_id": "ecog",
  "criterion_label": "ECOG performance status documented (typically 0–2)",
  "policy_citation": "Aetna CPB 0890 §III.C",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "ecog",
  "status": "met",
  "excerpt": "ECOG performance status: 1 (assessed 2026-04-30).",
  "sourceDocument": "Progress Note 2026-04-30 — Dr. Zhang",
  "confidence": 0.99
}
    chart.extract_evidence·460ms10:30:00.833
    ›Input
    {
  "criterion_id": "no_irae",
  "criterion_label": "No grade ≥3 immune-related adverse event prompting discontinuation",
  "policy_citation": "Aetna CPB 0890 §III.D",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_irae",
  "status": "met",
  "excerpt": "No grade ≥3 immune-related AE on review of last 6 cycles. CTCAE assessment normal.",
  "sourceDocument": "Toxicity Review 2026-04-30 — Dr. Zhang",
  "confidence": 0.94
}
    Output
    {
  "metCount": 5,
  "partialCount": 0,
  "missingCount": 0,
  "avgConfidence": 0.974
}
    Modelclaude-opus-4-7@20260318
    Promptauthora-evx-4.7.2
    Statuscompleted
  4. 04CMS-0057-F Compliance159ms·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·49ms10:30:01.392
    ›Input
    {
  "urgency": "routine",
  "slaWindowHours": 168,
  "payerId": "aetna"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 164
}
    compliance.check_denial_reason_specificity·58ms10:30:01.441
    ›Input
    {
  "policyId": "aetna-pembrolizumab-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·52ms10:30:01.499
    ›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. 05Submission1.04s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by Aetna. 278/13 response parsed (HCR01=A1).
    Tool calls (3)
    fhir.build_pas_bundle·161ms10:30:01.551
    ›Input
    {
  "caseNumber": "AUT-2026-00189",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00189",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·760ms10:30:01.712
    ›Input
    {
  "endpoint": "https://developerportal.aetna.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00189"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "AETNA-273797"
}
    x12.parse_278_response·123ms10:30:02.472
    ›Input
    {
  "format": "005010X216",
  "correlationId": "AETNA-273797"
}
    ›Output 
    {
  "hcr01": "A1",
  "authNumber": "AET-2026-44009",
  "authPeriod": {
    "start": "2026-05-09",
    "end": "2026-11-09"
  }
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00189",
  "hcr01": "A1",
  "authNumber": "AET-2026-44009"
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-sub-2.2.0
    Statuscompleted
  6. 06Notification275ms·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·155ms10:30:02.595
    ›Input
    {
  "caseNumber": "AUT-2026-00189",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi Margaret — your Pembrolizumab 200mg IV q3w — Cycle 7 (continuation) has been approved. The imaging center will reach out to schedule.",
  "length": 132,
  "channel": "sms"
}
    ehr.draft_inbasket_message·120ms10:30:02.750
    ›Input
    {
  "caseNumber": "AUT-2026-00189",
  "recipientNpi": "1538196274",
  "urgency": "routine"
}
    ›Output 
    {
  "recipient": "Dr. Zhang",
  "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