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AUT-2026-00191

PET/CT skull base to mid-thigh — staging

Tia Jefferson · 44F · BCBS IL · Blue Cross Blue Choice PPO

Appeal in flight
Patient
NameTia Jefferson
DOBNov 4, 1981 · age 44
MRNMRN-011477
Member IDBCBSIL-712009334
StateIL
PlanBlue Cross Blue Choice PPO
Ordering provider
NameWei Zhang, MD
NPI1538196274
SpecialtyMedical Oncology
OrganizationMission Cancer Center
Order
CPT
78815
ICD-10
C50.911C77.3
Service dateMay 11, 2026
UrgencyUrgent
Est. cost$5,650
Clinical narrative
44F with newly diagnosed invasive ductal carcinoma right breast, clinically T2N1. Path-confirmed with axillary node biopsy. Considering neoadjuvant chemo. PET/CT requested for accurate staging given clinical N1 disease.
Evidence: 5 source documents
  • ·Pathology Report 2026-04-22
  • ·NCCN Breast Cancer 2026 v3
  • ·Imaging History
  • ·Tumor Board Note 2026-04-28
Criteria evaluation
BCBS IL Medical Policy MED.00104

PET/CT for Oncologic Staging

4 met · 1 partial · 0 missing · 5 total
Tissue diagnosis of malignancy confirmed
Met
“Pathology: Invasive ductal carcinoma, ER+/PR+/HER2-. Axillary node biopsy positive.”
Pathology Report 2026-04-22
confidence 1.00
Citation: BCBS IL MED.00104 §III.A
Indication: initial staging, restaging, or response assessment
Met
“Clinical T2N1 — NCCN BINV-1 supports PET/CT in N1+ initial staging when distant disease is suspected.”
NCCN Breast Cancer 2026 v3
confidence 0.91
Citation: NCCN guideline-specific
Conventional imaging attempted or insufficient
Partial
“CT chest/abd/pelvis with contrast 2026-04-25; bone scan not yet performed. Provider citing PET/CT as superior single study.”
Imaging History
confidence 0.74
Citation: BCBS IL MED.00104 §III.C
Results will affect management
Met
“Result will determine neoadjuvant vs adjuvant approach and de-escalation candidacy.”
Tumor Board Note 2026-04-28
confidence 0.92
Citation: BCBS IL MED.00104 §III.D
No PET within 90 days unless restaging interval
Met
“No prior PET/CT on record.”
Imaging History
confidence 1.00
Citation: BCBS IL MED.00104 §III.E
Decision
Denied
Conventional imaging not exhausted per medical policy; bone scan available, no documented contraindication.
Decided by Dr. R. Holm, BCBS IL · Medical director2d ago
Agent trace · run run_aut-2026-00191_66475

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 tokens5,275 in · 2,316 out
Total cost$0.1413
  1. 01Patient Context562ms·544 / 234 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·177ms14:30:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-011477"
}
    ›Output 
    {
  "id": "pt-jefferson",
  "name": "Jefferson, Tia",
  "birthDate": "1981-11-04",
  "gender": "female",
  "address": {
    "state": "IL",
    "country": "US"
  }
}
    fhir.search_coverage·142ms14:30:00.177
    ›Input
    {
  "patient": "pt-jefferson",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-jefferson",
    "payor": "Blue Cross Blue Shield of Illinois",
    "plan": "Blue Cross Blue Choice PPO",
    "subscriberId": "BCBSIL-712009334",
    "status": "active"
  }
}
    fhir.search_encounter·243ms14:30:00.319
    ›Input
    {
  "patient": "pt-jefferson",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-tissue_diagnosis",
      "type": "AMB",
      "source": "Pathology Report 2026-04-22"
    },
    {
      "id": "enc-staging_indication",
      "type": "AMB",
      "source": "NCCN Breast Cancer 2026 v3"
    },
    {
      "id": "enc-alt_imaging_attempted",
      "type": "AMB",
      "source": "Imaging History"
    },
    {
      "id": "enc-results_actionable",
      "type": "AMB",
      "source": "Tumor Board Note 2026-04-28"
    }
  ]
}
    Output
    {
  "patientId": "pt-jefferson",
  "coverageId": "cov-pt-jefferson",
  "recentEncounterCount": 4,
  "ageAtService": 44
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match279ms·321 / 182 tok·$0.0010
    Thinking
    Single high-confidence match: PET/CT for Oncologic Staging. 5 criteria current as of 2026-02-01.
    Tool calls (2)
    policy_index.lookup·102ms14:30:00.562
    ›Input
    {
  "payerId": "bcbs_il",
  "cpt": "78815",
  "plan": "Blue Cross Blue Choice PPO"
}
    ›Output 
    {
  "policyId": "bcbs-petct-staging-2026",
  "citation": "BCBS IL Medical Policy MED.00104",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·177ms14:30:00.664
    ›Input
    {
  "policyId": "bcbs-petct-staging-2026",
  "version": "2026-02-01"
}
    ›Output 
    {
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "tissue_diagnosis",
      "label": "Tissue diagnosis of malignancy confirmed",
      "source": "PayerPolicy"
    },
    {
      "id": "staging_indication",
      "label": "Indication: initial staging, restaging, or response assessment",
      "source": "NCCN"
    },
    {
      "id": "alt_imaging_attempted",
      "label": "Conventional imaging attempted or insufficient",
      "source": "PayerPolicy"
    },
    {
      "id": "results_actionable",
      "label": "Results will affect management",
      "source": "PayerPolicy"
    },
    {
      "id": "no_recent_pet",
      "label": "No PET within 90 days unless restaging interval",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "bcbs-petct-staging-2026",
  "criteriaCount": 5
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction495ms·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·426ms14:30:00.899
    ›Input
    {
  "criterion_id": "tissue_diagnosis",
  "criterion_label": "Tissue diagnosis of malignancy confirmed",
  "policy_citation": "BCBS IL MED.00104 §III.A",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "tissue_diagnosis",
  "status": "met",
  "excerpt": "Pathology: Invasive ductal carcinoma, ER+/PR+/HER2-. Axillary node biopsy positive.",
  "sourceDocument": "Pathology Report 2026-04-22",
  "confidence": 1
}
    chart.extract_evidence·430ms14:30:00.897
    ›Input
    {
  "criterion_id": "staging_indication",
  "criterion_label": "Indication: initial staging, restaging, or response assessment",
  "policy_citation": "NCCN guideline-specific",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "staging_indication",
  "status": "met",
  "excerpt": "Clinical T2N1 — NCCN BINV-1 supports PET/CT in N1+ initial staging when distant disease is suspected.",
  "sourceDocument": "NCCN Breast Cancer 2026 v3",
  "confidence": 0.91
}
    chart.extract_evidence·360ms14:30:00.878
    ›Input
    {
  "criterion_id": "alt_imaging_attempted",
  "criterion_label": "Conventional imaging attempted or insufficient",
  "policy_citation": "BCBS IL MED.00104 §III.C",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "alt_imaging_attempted",
  "status": "partial",
  "excerpt": "CT chest/abd/pelvis with contrast 2026-04-25; bone scan not yet performed. Provider citing PET/CT as superior single study.",
  "sourceDocument": "Imaging History",
  "confidence": 0.74
}
    chart.extract_evidence·447ms14:30:00.868
    ›Input
    {
  "criterion_id": "results_actionable",
  "criterion_label": "Results will affect management",
  "policy_citation": "BCBS IL MED.00104 §III.D",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "results_actionable",
  "status": "met",
  "excerpt": "Result will determine neoadjuvant vs adjuvant approach and de-escalation candidacy.",
  "sourceDocument": "Tumor Board Note 2026-04-28",
  "confidence": 0.92
}
    chart.extract_evidence·494ms14:30:00.842
    ›Input
    {
  "criterion_id": "no_recent_pet",
  "criterion_label": "No PET within 90 days unless restaging interval",
  "policy_citation": "BCBS IL MED.00104 §III.E",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_recent_pet",
  "status": "met",
  "excerpt": "No prior PET/CT on record.",
  "sourceDocument": "Imaging History",
  "confidence": 1
}
    Output
    {
  "metCount": 4,
  "partialCount": 1,
  "missingCount": 0,
  "avgConfidence": 0.914
}
    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 Compliance151ms·380 / 140 tok·$0.0009
    Thinking
    72-hour expedited window validated. Denial-reason fields covered. 18/18 public-reporting fields populated.
    Tool calls (3)
    compliance.evaluate_sla·57ms14:30:01.336
    ›Input
    {
  "urgency": "urgent",
  "slaWindowHours": 72,
  "payerId": "bcbs_il"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 68
}
    compliance.check_denial_reason_specificity·55ms14:30:01.393
    ›Input
    {
  "policyId": "bcbs-petct-staging-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·39ms14:30:01.448
    ›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. 05Submission1.14s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by BCBS IL. 278/13 response parsed (HCR01=A3).
    Tool calls (3)
    fhir.build_pas_bundle·190ms14:30:01.487
    ›Input
    {
  "caseNumber": "AUT-2026-00191",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00191",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·837ms14:30:01.677
    ›Input
    {
  "endpoint": "https://bcbs_il.payer.example/fhir/Claim/$submit",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00191"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "BCBS_IL-321234"
}
    x12.parse_278_response·111ms14:30:02.514
    ›Input
    {
  "format": "005010X216",
  "correlationId": "BCBS_IL-321234"
}
    ›Output 
    {
  "hcr01": "A3",
  "authPeriod": {}
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00191",
  "hcr01": "A3",
  "authNumber": null
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-sub-2.2.0
    Statuscompleted
  6. 06Notification261ms·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·157ms14:30:02.625
    ›Input
    {
  "caseNumber": "AUT-2026-00191",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi Tia — your PET/CT skull base to mid-thigh — staging request is moving through review. We'll text again as soon as there's an update.",
  "length": 138,
  "channel": "sms"
}
    ehr.draft_inbasket_message·104ms14:30:02.782
    ›Input
    {
  "caseNumber": "AUT-2026-00191",
  "recipientNpi": "1538196274",
  "urgency": "urgent"
}
    ›Output 
    {
  "recipient": "Dr. Zhang",
  "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