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AUT-2026-00192

Tirzepatide (Zepbound) 5mg weekly — initial 6 month

Ellen Schultz · 39F · Aetna · Aetna Choice POS II

Denied
Patient
NameEllen Schultz
DOBJun 18, 1985 · age 39
MRNMRN-012331
Member IDAET-883119052
StateOH
PlanAetna Choice POS II
Ordering provider
NameSara Niemi, MD
NPI1245678901
SpecialtyEndocrinology
OrganizationSunset Endocrine Group
Order
CPT
—
ICD-10
E66.01Z68.41E78.5
Service dateMay 9, 2026
UrgencyRoutine
Est. cost$1,090
Clinical narrative
39F with BMI 41.2 and T2DM. PCP requested tirzepatide for chronic weight management. Patient has documented HTN and T2DM. Lifestyle program enrollment unclear in chart.
Evidence: 5 source documents
  • ·Vitals 2026-04-30
  • ·Progress Note 2026-04-30
  • ·Med History query
  • ·—
Criteria evaluation
Aetna Clinical Policy Bulletin 0040

Tirzepatide (Zepbound) for Chronic Weight Management

2 met · 0 partial · 3 missing · 5 total
BMI ≥30, OR BMI ≥27 with weight-related comorbidity
Met
“BMI 41.2 (height 5'5", weight 248 lb). Documented 2026-04-30.”
Vitals 2026-04-30
confidence 1.00
Citation: FDA label + Aetna CPB 0040
Lifestyle intervention attempt ≥6 months
Missing
“No structured 6-month lifestyle program enrollment documented. Patient mentions 'tried diet on own' x 4 months.”
Progress Note 2026-04-30
confidence 0.62
Citation: Aetna CPB 0040 §B.2
No personal/family history of MEN2 or MTC
Met
“No personal/family history of MEN2 or MTC. Family history reviewed.”
Progress Note 2026-04-30
confidence 0.97
Citation: FDA Black Box
Step therapy completed OR contraindicated
Missing
“No prior weight-loss medication trial documented.”
Med History query
confidence 0.95
Citation: Aetna CPB 0040 §B.4
≥5% weight loss for continuation (after 6 months)
Missing
“N/A — initial request, not continuation.”
—
confidence 1.00
Citation: FDA label
Decision
Denied
Two of five criteria not met. Specific gaps cited above. Resubmit with lifestyle program documentation and step-therapy trial.
Decided by Aetna UM · UM nurse20h ago
Agent trace · run run_aut-2026-00192_62816

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 tokens5,238 in · 2,354 out
Total cost$0.1414
  1. 01Patient Context520ms·493 / 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·189ms08:30:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-012331"
}
    ›Output 
    {
  "id": "pt-schultz",
  "name": "Schultz, Ellen",
  "birthDate": "1985-06-18",
  "gender": "female",
  "address": {
    "state": "OH",
    "country": "US"
  }
}
    fhir.search_coverage·153ms08:30:00.189
    ›Input
    {
  "patient": "pt-schultz",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-schultz",
    "payor": "Aetna (CVS Health)",
    "plan": "Aetna Choice POS II",
    "subscriberId": "AET-883119052",
    "status": "active"
  }
}
    fhir.search_encounter·178ms08:30:00.342
    ›Input
    {
  "patient": "pt-schultz",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-bmi",
      "type": "AMB",
      "source": "Vitals 2026-04-30"
    },
    {
      "id": "enc-lifestyle",
      "type": "AMB",
      "source": "Progress Note 2026-04-30"
    },
    {
      "id": "enc-no_men2",
      "type": "AMB",
      "source": "Progress Note 2026-04-30"
    },
    {
      "id": "enc-step_therapy",
      "type": "AMB",
      "source": "Med History query"
    }
  ]
}
    Output
    {
  "patientId": "pt-schultz",
  "coverageId": "cov-pt-schultz",
  "recentEncounterCount": 4,
  "ageAtService": 39
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match228ms·335 / 189 tok·$0.0010
    Thinking
    Single high-confidence match: Tirzepatide (Zepbound) for Chronic Weight Management. 5 criteria current as of 2026-04-01.
    Tool calls (2)
    policy_index.lookup·80ms08:30:00.520
    ›Input
    {
  "payerId": "aetna",
  "plan": "Aetna Choice POS II"
}
    ›Output 
    {
  "policyId": "aetna-tirzepatide-2026",
  "citation": "Aetna Clinical Policy Bulletin 0040",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·148ms08:30:00.600
    ›Input
    {
  "policyId": "aetna-tirzepatide-2026",
  "version": "2026-04-01"
}
    ›Output 
    {
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "bmi",
      "label": "BMI ≥30, OR BMI ≥27 with weight-related comorbidity",
      "source": "PayerPolicy"
    },
    {
      "id": "lifestyle",
      "label": "Lifestyle intervention attempt ≥6 months",
      "source": "PayerPolicy"
    },
    {
      "id": "no_men2",
      "label": "No personal/family history of MEN2 or MTC",
      "source": "PayerPolicy"
    },
    {
      "id": "step_therapy",
      "label": "Step therapy completed OR contraindicated",
      "source": "PayerPolicy"
    },
    {
      "id": "weight_loss_continuation",
      "label": "≥5% weight loss for continuation (after 6 months)",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "aetna-tirzepatide-2026",
  "criteriaCount": 5
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction454ms·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=2, partial=0, missing=3.
    Tool calls (5)
    chart.extract_evidence·358ms08:30:00.794
    ›Input
    {
  "criterion_id": "bmi",
  "criterion_label": "BMI ≥30, OR BMI ≥27 with weight-related comorbidity",
  "policy_citation": "FDA label + Aetna CPB 0040",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "bmi",
  "status": "met",
  "excerpt": "BMI 41.2 (height 5'5\", weight 248 lb). Documented 2026-04-30.",
  "sourceDocument": "Vitals 2026-04-30",
  "confidence": 1
}
    chart.extract_evidence·245ms08:30:00.795
    ›Input
    {
  "criterion_id": "lifestyle",
  "criterion_label": "Lifestyle intervention attempt ≥6 months",
  "policy_citation": "Aetna CPB 0040 §B.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "lifestyle",
  "status": "missing",
  "excerpt": "No structured 6-month lifestyle program enrollment documented. Patient mentions 'tried diet on own' x 4 months.",
  "sourceDocument": "Progress Note 2026-04-30",
  "confidence": 0.62
}
    chart.extract_evidence·402ms08:30:00.800
    ›Input
    {
  "criterion_id": "no_men2",
  "criterion_label": "No personal/family history of MEN2 or MTC",
  "policy_citation": "FDA Black Box",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_men2",
  "status": "met",
  "excerpt": "No personal/family history of MEN2 or MTC. Family history reviewed.",
  "sourceDocument": "Progress Note 2026-04-30",
  "confidence": 0.97
}
    chart.extract_evidence·267ms08:30:00.762
    ›Input
    {
  "criterion_id": "step_therapy",
  "criterion_label": "Step therapy completed OR contraindicated",
  "policy_citation": "Aetna CPB 0040 §B.4",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "step_therapy",
  "status": "missing",
  "excerpt": "No prior weight-loss medication trial documented.",
  "sourceDocument": "Med History query",
  "confidence": 0.95
}
    chart.extract_evidence·304ms08:30:00.748
    ›Input
    {
  "criterion_id": "weight_loss_continuation",
  "criterion_label": "≥5% weight loss for continuation (after 6 months)",
  "policy_citation": "FDA label",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "weight_loss_continuation",
  "status": "missing",
  "excerpt": "N/A — initial request, not continuation.",
  "sourceDocument": "—",
  "confidence": 1
}
    Output
    {
  "metCount": 2,
  "partialCount": 0,
  "missingCount": 3,
  "avgConfidence": 0.908
}
    Notes
    • ·3 criteriona have no extractable evidence in the current chart window.
    Modelclaude-opus-4-7@20260318
    Promptauthora-evx-4.7.2
    Statuscompleted
  4. 04CMS-0057-F Compliance164ms·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·71ms08:30:01.202
    ›Input
    {
  "urgency": "routine",
  "slaWindowHours": 168,
  "payerId": "aetna"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 164
}
    compliance.check_denial_reason_specificity·52ms08:30:01.273
    ›Input
    {
  "policyId": "aetna-tirzepatide-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·41ms08:30:01.325
    ›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. 05Submission1.23s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by Aetna. 278/13 response parsed (HCR01=A3).
    Tool calls (3)
    fhir.build_pas_bundle·199ms08:30:01.366
    ›Input
    {
  "caseNumber": "AUT-2026-00192",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00192",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·940ms08:30:01.565
    ›Input
    {
  "endpoint": "https://developerportal.aetna.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00192"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "AETNA-148085"
}
    x12.parse_278_response·89ms08:30:02.505
    ›Input
    {
  "format": "005010X216",
  "correlationId": "AETNA-148085"
}
    ›Output 
    {
  "hcr01": "A3",
  "authPeriod": {}
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00192",
  "hcr01": "A3",
  "authNumber": null
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-sub-2.2.0
    Statuscompleted
  6. 06Notification262ms·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·137ms08:30:02.594
    ›Input
    {
  "caseNumber": "AUT-2026-00192",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi Ellen — your Tirzepatide (Zepbound) 5mg weekly — initial 6 month request is moving through review. We'll text again as soon as there's an update.",
  "length": 138,
  "channel": "sms"
}
    ehr.draft_inbasket_message·125ms08:30:02.731
    ›Input
    {
  "caseNumber": "AUT-2026-00192",
  "recipientNpi": "1245678901",
  "urgency": "routine"
}
    ›Output 
    {
  "recipient": "Dr. Niemi",
  "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