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AUT-2026-00190

L4-L5 TLIF (transforaminal lumbar interbody fusion)

James Thompson · 56M · Cigna · Cigna OAP

P2P scheduled
Patient
NameJames Thompson
DOBJul 22, 1969 · age 56
MRNMRN-011009
Member IDCIG-668214093
StateCO
PlanCigna OAP
Ordering provider
NameDaniel Kim, DO
NPI1567890123
SpecialtyNeurosurgery
OrganizationBay Spine Institute
Order
CPT
226332284020930
ICD-10
M43.16M48.06M51.36
Service dateMay 15, 2026
FacilityBay Spine Surgical Center
UrgencyRoutine
Est. cost$47,500
Clinical narrative
56M with 9 months of progressive low back pain and bilateral L5 radiculopathy. Failed 12 weeks of supervised PT, 8 weeks of NSAIDs, two epidural injections. MRI: Grade I spondylolisthesis L4-L5 with severe central stenosis. Flexion-extension films: 4mm motion. ODI 42. BMI 31. Former smoker, quit 6 months ago.
Evidence: 7 source documents
  • ·Pre-op H&P 2026-05-01 — Dr. Kim
  • ·PT records + Pain Mgmt notes
  • ·Radiology Reports 2026-04-10 + 2026-04-12
  • ·Pre-op H&P 2026-05-01
  • ·Functional Assessment 2026-04-22
  • ·Pre-op Labs 2026-04-30
Criteria evaluation
Cigna Medical Coverage Policy 0303

Lumbar Spinal Fusion (Decompression with Fusion)

6 met · 1 partial · 0 missing · 7 total
Symptoms ≥6 months
Met
“9 months of progressive symptoms; bilateral L5 radiculopathy x 6 months.”
Pre-op H&P 2026-05-01 — Dr. Kim
confidence 0.98
Citation: Cigna MCP-0303 §A.1
≥6 weeks supervised conservative care
Met
“12 weeks PT (24 sessions, supervised); 8 weeks NSAIDs; 2 ESI dates 2025-12-04, 2026-01-22.”
PT records + Pain Mgmt notes
confidence 0.97
Citation: Cigna MCP-0303 §A.2
Imaging confirms structural pathology
Met
“MRI: Grade I spondylolisthesis L4-L5 with severe central canal stenosis (CSF effacement). Flex-ext: 4mm sagittal translation.”
Radiology Reports 2026-04-10 + 2026-04-12
confidence 0.95
Citation: Cigna MCP-0303 §A.3
Imaging correlates with symptoms
Met
“Bilateral L5 dermatome symptoms correlate with L4-L5 stenosis on imaging.”
Pre-op H&P 2026-05-01
confidence 0.93
Citation: Cigna MCP-0303 §A.4
Functional limitation: ODI ≥30 (or equivalent)
Met
“ODI 42 (severe disability) — assessed 2026-04-22.”
Functional Assessment 2026-04-22
confidence 0.99
Citation: Cigna MCP-0303 §A.5
Smoking cessation addressed (if smoker)
Partial
“Former smoker, quit 6 months ago. Cessation counseling documented in chart 2025-09-15. Cigna policy requires 12 months tobacco-free for elective fusion.”
Pre-op H&P 2026-05-01
confidence 0.88
Citation: Cigna MCP-0303 §A.6
No untreated active infection
Met
“WBC 7.2, ESR 12, CRP 3.1, no skin breakdown or infection.”
Pre-op Labs 2026-04-30
confidence 1.00
Citation: Cigna MCP-0303 §B.1
Decision
Pended for info
Six of seven criteria fully met; smoking cessation criterion partially met (6 months vs. 12 months policy requirement). Recent NASS evidence supports 6-month cessation as adequate; recommend P2P to discuss policy interpretation and patient-specific factors.
Decided by Dr. M. Lessler, Cigna · Medical director2d ago
Agent trace · run run_aut-2026-00190_38589

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 duration2.89s
Agents6
Total tokens5,751 in · 2,715 out
Total cost$0.1751
  1. 01Patient Context471ms·535 / 265 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·145ms14:30:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-011009"
}
    ›Output 
    {
  "id": "pt-thompson",
  "name": "Thompson, James",
  "birthDate": "1969-07-22",
  "gender": "male",
  "address": {
    "state": "CO",
    "country": "US"
  }
}
    fhir.search_coverage·117ms14:30:00.145
    ›Input
    {
  "patient": "pt-thompson",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-thompson",
    "payor": "Cigna",
    "plan": "Cigna OAP",
    "subscriberId": "CIG-668214093",
    "status": "active"
  }
}
    fhir.search_encounter·209ms14:30:00.262
    ›Input
    {
  "patient": "pt-thompson",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-symptoms_duration",
      "type": "AMB",
      "source": "Pre-op H&P 2026-05-01 — Dr. Kim"
    },
    {
      "id": "enc-conservative_6w",
      "type": "AMB",
      "source": "PT records + Pain Mgmt notes"
    },
    {
      "id": "enc-imaging_pathology",
      "type": "AMB",
      "source": "Radiology Reports 2026-04-10 + 2026-04-12"
    },
    {
      "id": "enc-imaging_correlates",
      "type": "AMB",
      "source": "Pre-op H&P 2026-05-01"
    }
  ]
}
    Output
    {
  "patientId": "pt-thompson",
  "coverageId": "cov-pt-thompson",
  "recentEncounterCount": 4,
  "ageAtService": 56
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match237ms·366 / 190 tok·$0.0011
    Thinking
    Single high-confidence match: Lumbar Spinal Fusion (Decompression with Fusion). 7 criteria current as of 2026-02-20.
    Tool calls (2)
    policy_index.lookup·82ms14:30:00.471
    ›Input
    {
  "payerId": "cigna",
  "cpt": "22633",
  "plan": "Cigna OAP"
}
    ›Output 
    {
  "policyId": "cigna-lumbar-fusion-2026",
  "citation": "Cigna Medical Coverage Policy 0303",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·155ms14:30:00.553
    ›Input
    {
  "policyId": "cigna-lumbar-fusion-2026",
  "version": "2026-02-20"
}
    ›Output 
    {
  "criteriaCount": 7,
  "criteria": [
    {
      "id": "symptoms_duration",
      "label": "Symptoms ≥6 months",
      "source": "NASS"
    },
    {
      "id": "conservative_6w",
      "label": "≥6 weeks supervised conservative care",
      "source": "NASS"
    },
    {
      "id": "imaging_pathology",
      "label": "Imaging confirms structural pathology",
      "source": "NASS"
    },
    {
      "id": "imaging_correlates",
      "label": "Imaging correlates with symptoms",
      "source": "NASS"
    },
    {
      "id": "odi",
      "label": "Functional limitation: ODI ≥30 (or equivalent)",
      "source": "NASS"
    },
    {
      "id": "smoking",
      "label": "Smoking cessation addressed (if smoker)",
      "source": "NASS"
    },
    {
      "id": "no_active_infection",
      "label": "No untreated active infection",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "cigna-lumbar-fusion-2026",
  "criteriaCount": 7
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction570ms·3,340 / 1,580 tok·$0.1686
    Thinking
    Fanned out 7 parallel extract_evidence calls against chart resources. Each criterion returns a quoted excerpt with source provenance and a confidence score. Met=6, partial=1, missing=0.
    Tool calls (7)
    chart.extract_evidence·522ms14:30:00.752
    ›Input
    {
  "criterion_id": "symptoms_duration",
  "criterion_label": "Symptoms ≥6 months",
  "policy_citation": "Cigna MCP-0303 §A.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "symptoms_duration",
  "status": "met",
  "excerpt": "9 months of progressive symptoms; bilateral L5 radiculopathy x 6 months.",
  "sourceDocument": "Pre-op H&P 2026-05-01 — Dr. Kim",
  "confidence": 0.98
}
    chart.extract_evidence·423ms14:30:00.746
    ›Input
    {
  "criterion_id": "conservative_6w",
  "criterion_label": "≥6 weeks supervised conservative care",
  "policy_citation": "Cigna MCP-0303 §A.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "conservative_6w",
  "status": "met",
  "excerpt": "12 weeks PT (24 sessions, supervised); 8 weeks NSAIDs; 2 ESI dates 2025-12-04, 2026-01-22.",
  "sourceDocument": "PT records + Pain Mgmt notes",
  "confidence": 0.97
}
    chart.extract_evidence·359ms14:30:00.765
    ›Input
    {
  "criterion_id": "imaging_pathology",
  "criterion_label": "Imaging confirms structural pathology",
  "policy_citation": "Cigna MCP-0303 §A.3",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "imaging_pathology",
  "status": "met",
  "excerpt": "MRI: Grade I spondylolisthesis L4-L5 with severe central canal stenosis (CSF effacement). Flex-ext: 4mm sagittal translation.",
  "sourceDocument": "Radiology Reports 2026-04-10 + 2026-04-12",
  "confidence": 0.95
}
    chart.extract_evidence·461ms14:30:00.760
    ›Input
    {
  "criterion_id": "imaging_correlates",
  "criterion_label": "Imaging correlates with symptoms",
  "policy_citation": "Cigna MCP-0303 §A.4",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "imaging_correlates",
  "status": "met",
  "excerpt": "Bilateral L5 dermatome symptoms correlate with L4-L5 stenosis on imaging.",
  "sourceDocument": "Pre-op H&P 2026-05-01",
  "confidence": 0.93
}
    chart.extract_evidence·457ms14:30:00.762
    ›Input
    {
  "criterion_id": "odi",
  "criterion_label": "Functional limitation: ODI ≥30 (or equivalent)",
  "policy_citation": "Cigna MCP-0303 §A.5",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "odi",
  "status": "met",
  "excerpt": "ODI 42 (severe disability) — assessed 2026-04-22.",
  "sourceDocument": "Functional Assessment 2026-04-22",
  "confidence": 0.99
}
    chart.extract_evidence·511ms14:30:00.727
    ›Input
    {
  "criterion_id": "smoking",
  "criterion_label": "Smoking cessation addressed (if smoker)",
  "policy_citation": "Cigna MCP-0303 §A.6",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "smoking",
  "status": "partial",
  "excerpt": "Former smoker, quit 6 months ago. Cessation counseling documented in chart 2025-09-15. Cigna policy requires 12 months tobacco-free for elective fusion.",
  "sourceDocument": "Pre-op H&P 2026-05-01",
  "confidence": 0.88
}
    chart.extract_evidence·514ms14:30:00.764
    ›Input
    {
  "criterion_id": "no_active_infection",
  "criterion_label": "No untreated active infection",
  "policy_citation": "Cigna MCP-0303 §B.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_active_infection",
  "status": "met",
  "excerpt": "WBC 7.2, ESR 12, CRP 3.1, no skin breakdown or infection.",
  "sourceDocument": "Pre-op Labs 2026-04-30",
  "confidence": 1
}
    Output
    {
  "metCount": 6,
  "partialCount": 1,
  "missingCount": 0,
  "avgConfidence": 0.957
}
    Notes
    • ·1 criterion partially evidenced — chart extraction suggests resubmittable with one additional artifact.
    Modelclaude-opus-4-7@20260318
    Promptauthora-evx-4.7.2
    Statuscompleted
  4. 04CMS-0057-F Compliance150ms·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·55ms14:30:01.278
    ›Input
    {
  "urgency": "routine",
  "slaWindowHours": 168,
  "payerId": "cigna"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 164
}
    compliance.check_denial_reason_specificity·55ms14:30:01.333
    ›Input
    {
  "policyId": "cigna-lumbar-fusion-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·40ms14:30:01.388
    ›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. 05Submission1.21s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by Cigna. 278/13 response parsed (HCR01=A4).
    Tool calls (3)
    fhir.build_pas_bundle·197ms14:30:01.428
    ›Input
    {
  "caseNumber": "AUT-2026-00190",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00190",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·921ms14:30:01.625
    ›Input
    {
  "endpoint": "https://developer.cigna.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00190"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "CIGNA-427185"
}
    x12.parse_278_response·93ms14:30:02.546
    ›Input
    {
  "format": "005010X216",
  "correlationId": "CIGNA-427185"
}
    ›Output 
    {
  "hcr01": "A4",
  "authPeriod": {}
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00190",
  "hcr01": "A4",
  "authNumber": null
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-sub-2.2.0
    Statuscompleted
  6. 06Notification248ms·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·134ms14:30:02.639
    ›Input
    {
  "caseNumber": "AUT-2026-00190",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi James — your L4-L5 TLIF (transforaminal lumbar interbody fusion) request is moving through review. We'll text again as soon as there's an update.",
  "length": 138,
  "channel": "sms"
}
    ehr.draft_inbasket_message·114ms14:30:02.773
    ›Input
    {
  "caseNumber": "AUT-2026-00190",
  "recipientNpi": "1567890123",
  "urgency": "routine"
}
    ›Output 
    {
  "recipient": "Dr. Kim",
  "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