AUT-2026-00193

Transcranial Magnetic Stimulation — 36-session course

Emeka Okafor · 47M · UHC · UnitedHealthcare Optum Behavioral

ApprovedPrint authorization letter

Patient

NameEmeka Okafor

DOBJan 9, 1979 · age 47

MRNMRN-013002

Member IDUHC-220197553

StateGA

PlanUnitedHealthcare Optum Behavioral

Ordering provider

NameLucia Franco, MD

NPI1456789012

SpecialtyPsychiatry

OrganizationNorthgate Behavioral Health

Order

CPT

90867 90868

ICD-10

F33.2

Service dateMay 16, 2026

FacilityNorthgate Behavioral Health TMS Suite

UrgencyRoutine

Est. cost$14,400

Clinical narrative

47M with recurrent severe MDD, current episode 14 months. Failed sertraline 200mg x 8 weeks, then bupropion XL 450mg x 10 weeks at therapeutic doses. Completed 16-session CBT course. PHQ-9 currently 22 (severe). No seizure history; no contraindications.

Evidence: 5 source documents

·Psych Eval 2026-04-15 — Dr. Franco
·Med History + Pharmacy 2026-04-15
·Therapy notes summary
·Pre-TMS Screen 2026-04-15
·Validated assessment

Criteria evaluation

Optum Behavioral Health Medical Policy BH-005

Transcranial Magnetic Stimulation for Treatment-Resistant Depression

5 met · 0 partial · 0 missing · 5 total

Diagnosis of major depressive disorder

Met

“DSM-5 MDD recurrent, severe, current episode 14 months.”

Psych Eval 2026-04-15 — Dr. Franco

confidence 0.99

Citation: Optum BH-005 §A.1

≥2 prior antidepressants from different classes failed

Met

“Sertraline 200mg x 8w (SSRI), then bupropion XL 450mg x 10w (NDRI). Inadequate response on both.”

Med History + Pharmacy 2026-04-15

confidence 0.97

Citation: Optum BH-005 §A.2

Psychotherapy attempted

Met

“16 sessions CBT 2025-08-04 → 2026-01-12 with licensed psychologist.”

Therapy notes summary

confidence 0.95

Citation: Optum BH-005 §A.3

No seizure history or ferromagnetic implants

Met

“No seizure history. No intracranial metal, cochlear implant, or other ferromagnetic device.”

Pre-TMS Screen 2026-04-15

confidence 1.00

Citation: FDA label

PHQ-9 ≥15 (moderate-severe)

Met

“PHQ-9: 22 (2026-04-15). Prior PHQ-9: 19 (2025-12-10), 21 (2025-09-04).”

Validated assessment

confidence 1.00

Citation: Optum BH-005 §A.5

Decision

Approved

Auth #UHC-2026-119477 · May 15, 2026 → Sep 15, 2026

Treatment-resistant depression by FDA criteria; psychotherapy attempted; no contraindications; severity validated.

Decided by L. Martinez, RN · UM nurse12h ago

Submission timeline

12h agoPayer
Approved — Auth #UHC-2026-119477, 36 sessions
Optum BH
2d agoSystem
PAS Bundle submitted to Optum BH
2d agoProvider
TMS PA initiated
Dr. Franco
2d agoAI
All 5 criteria evidenced

Wire format

{
  "resourceType": "Bundle",
  "id": "pas-request-AUT-2026-00193",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"
    ]
  },
  "type": "collection",
  "timestamp": "2026-05-31T21:43:49.259Z",
  "entry": [
    {
      "fullUrl": "urn:uuid:0c39f6ef-2785-44be-b346-490e4392984a",
      "resource": {
        "resourceType": "Claim",
        "id": "0c39f6ef-2785-44be-b346-490e4392984a",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
          ]
        },
        "identifier": [
          {
            "system": "https://authora.health/cases",
            "value": "AUT-2026-00193"
          }
        ],
        "status": "active",
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/claim-type",
              "code": "institutional"
            }
          ]
        },
        "use": "preauthorization",
        "patient": {
          "reference": "urn:uuid:76be07f2-a05e-4d32-965b-6ae23f72d822"
        },
        "created": "2026-05-06T14:30:00.000Z",
        "insurer": {
          "reference": "urn:uuid:dd318447-f5c1-4e01-89d7-2443112954d5"
        },
        "provider": {
          "reference": "urn:uuid:7906c867-04b5-49c7-a607-b6a25460a5c9"
        },
        "priority": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/processpriority",
              "code": "normal"
            }
          ]
        },
        "careTeam": [
          {
            "sequence": 1,
            "provider": {
              "reference": "urn:uuid:3724edfd-05e6-4aad-8c9e-404eafa1004e"
            },
            "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": "F33.2",
                  "display": "Major depressive disorder, recurrent severe without psychotic features"
                }
              ]
            }
          }
        ],
        "insurance": [
          {
            "sequence": 1,
            "focal": true,
            "coverage": {
              "reference": "urn:uuid:3e666a58-1f1c-436e-862b-a2c650c95c9f"
            }
          }
        ],
        "item": [
          {
            "sequence": 1,
            "careTeamSequence": [
              1
            ],
            "diagnosisSequence": [
              1
            ],
            "productOrService": {
              "coding": [
                {
                  "system": "http://www.ama-assn.org/go/cpt",
                  "code": "90867",
                  "display": "TMS therapy, initial"
                }
              ]
            },
            "servicedDate": "2026-05-16",
            "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"
                    }
                  ]
                }
              }
            ]
          },
          {
            "sequence": 2,
            "careTeamSequence": [
              1
            ],
            "diagnosisSequence": [
              1
            ],
            "productOrService": {
              "coding": [
                {
                  "system": "http://www.ama-assn.org/go/cpt",
                  "code": "90868",
                  "display": "TMS therapy, subsequent delivery"
                }
              ]
            },
            "servicedDate": "2026-05-16",
            "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:76be07f2-a05e-4d32-965b-6ae23f72d822",
      "resource": {
        "resourceType": "Patient",
        "id": "76be07f2-a05e-4d32-965b-6ae23f72d822",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-mbi",
            "value": "UHC-220197553"
          },
          {
            "system": "https://authora.health/mrn",
            "value": "MRN-013002"
          }
        ],
        "name": [
          {
            "family": "Okafor",
            "given": [
              "Emeka"
            ]
          }
        ],
        "gender": "male",
        "birthDate": "1979-01-09",
        "address": [
          {
            "state": "GA",
            "country": "US"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:3e666a58-1f1c-436e-862b-a2c650c95c9f",
      "resource": {
        "resourceType": "Coverage",
        "id": "3e666a58-1f1c-436e-862b-a2c650c95c9f",
        "status": "active",
        "subscriberId": "UHC-220197553",
        "beneficiary": {
          "reference": "urn:uuid:76be07f2-a05e-4d32-965b-6ae23f72d822"
        },
        "payor": [
          {
            "reference": "urn:uuid:dd318447-f5c1-4e01-89d7-2443112954d5"
          }
        ],
        "class": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "plan"
                }
              ]
            },
            "value": "UnitedHealthcare Optum Behavioral"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:dd318447-f5c1-4e01-89d7-2443112954d5",
      "resource": {
        "resourceType": "Organization",
        "id": "dd318447-f5c1-4e01-89d7-2443112954d5",
        "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:7906c867-04b5-49c7-a607-b6a25460a5c9",
      "resource": {
        "resourceType": "Organization",
        "id": "7906c867-04b5-49c7-a607-b6a25460a5c9",
        "name": "Northgate Behavioral Health",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/organization-type",
                "code": "prov"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:3724edfd-05e6-4aad-8c9e-404eafa1004e",
      "resource": {
        "resourceType": "Practitioner",
        "id": "3724edfd-05e6-4aad-8c9e-404eafa1004e",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-npi",
            "value": "1456789012"
          }
        ],
        "name": [
          {
            "family": "Franco",
            "given": [
              "Lucia"
            ],
            "suffix": [
              "MD"
            ]
          }
        ]
      }
    }
  ]
}

Payer connection

UnitedHealthcare

PARDD live

CRD

DTR

PAS

Agent trace · run run_aut-2026-00193_13171

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 duration3.05s

Agents6

Total tokens5,237 in · 2,361 out

Total cost$0.1414

01Patient Context532ms·487 / 272 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·150ms14:30:00.000

›Input

{
  "resourceType": "Patient",
  "identifier": "MRN-013002"
}

›Output

{
  "id": "pt-okafor",
  "name": "Okafor, Emeka",
  "birthDate": "1979-01-09",
  "gender": "male",
  "address": {
    "state": "GA",
    "country": "US"
  }
}

fhir.search_coverage·138ms14:30:00.150

›Input

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

›Output

{
  "coverage": {
    "id": "cov-pt-okafor",
    "payor": "UnitedHealthcare",
    "plan": "UnitedHealthcare Optum Behavioral",
    "subscriberId": "UHC-220197553",
    "status": "active"
  }
}

fhir.search_encounter·244ms14:30:00.288

›Input

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

›Output

{
  "encounters": [
    {
      "id": "enc-diagnosis_mdd",
      "type": "AMB",
      "source": "Psych Eval 2026-04-15 — Dr. Franco"
    },
    {
      "id": "enc-two_antidepressants",
      "type": "AMB",
      "source": "Med History + Pharmacy 2026-04-15"
    },
    {
      "id": "enc-psychotherapy",
      "type": "AMB",
      "source": "Therapy notes summary"
    },
    {
      "id": "enc-no_contraindication",
      "type": "AMB",
      "source": "Pre-TMS Screen 2026-04-15"
    }
  ]
}

Output

{
  "patientId": "pt-okafor",
  "coverageId": "cov-pt-okafor",
  "recentEncounterCount": 4,
  "ageAtService": 47
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pcx-2.4.1

Statuscompleted

02Policy Match223ms·340 / 189 tok·$0.0010

Thinking

Single high-confidence match: Transcranial Magnetic Stimulation for Treatment-Resistant Depression. 5 criteria current as of 2026-03-01.

Tool calls (2)

policy_index.lookup·91ms14:30:00.532

›Input

{
  "payerId": "uhc",
  "cpt": "90867",
  "plan": "UnitedHealthcare Optum Behavioral"
}

›Output

{
  "policyId": "uhc-tms-2026",
  "citation": "Optum Behavioral Health Medical Policy BH-005",
  "effectiveDate": "2026-01-01"
}

policy_index.fetch_criteria·132ms14:30:00.623

›Input

{
  "policyId": "uhc-tms-2026",
  "version": "2026-03-01"
}

›Output

{
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "diagnosis_mdd",
      "label": "Diagnosis of major depressive disorder",
      "source": "PayerPolicy"
    },
    {
      "id": "two_antidepressants",
      "label": "≥2 prior antidepressants from different classes failed",
      "source": "PayerPolicy"
    },
    {
      "id": "psychotherapy",
      "label": "Psychotherapy attempted",
      "source": "PayerPolicy"
    },
    {
      "id": "no_contraindication",
      "label": "No seizure history or ferromagnetic implants",
      "source": "PayerPolicy"
    },
    {
      "id": "phq9",
      "label": "PHQ-9 ≥15 (moderate-severe)",
      "source": "PayerPolicy"
    }
  ]
}

Output

{
  "policyId": "uhc-tms-2026",
  "criteriaCount": 5
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pmt-3.1.0

Statuscompleted

03Evidence Extraction532ms·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·481ms14:30:00.806

›Input

{
  "criterion_id": "diagnosis_mdd",
  "criterion_label": "Diagnosis of major depressive disorder",
  "policy_citation": "Optum BH-005 §A.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "diagnosis_mdd",
  "status": "met",
  "excerpt": "DSM-5 MDD recurrent, severe, current episode 14 months.",
  "sourceDocument": "Psych Eval 2026-04-15 — Dr. Franco",
  "confidence": 0.99
}

chart.extract_evidence·371ms14:30:00.771

›Input

{
  "criterion_id": "two_antidepressants",
  "criterion_label": "≥2 prior antidepressants from different classes failed",
  "policy_citation": "Optum BH-005 §A.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "two_antidepressants",
  "status": "met",
  "excerpt": "Sertraline 200mg x 8w (SSRI), then bupropion XL 450mg x 10w (NDRI). Inadequate response on both.",
  "sourceDocument": "Med History + Pharmacy 2026-04-15",
  "confidence": 0.97
}

chart.extract_evidence·417ms14:30:00.781

›Input

{
  "criterion_id": "psychotherapy",
  "criterion_label": "Psychotherapy attempted",
  "policy_citation": "Optum BH-005 §A.3",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "psychotherapy",
  "status": "met",
  "excerpt": "16 sessions CBT 2025-08-04 → 2026-01-12 with licensed psychologist.",
  "sourceDocument": "Therapy notes summary",
  "confidence": 0.95
}

chart.extract_evidence·394ms14:30:00.787

›Input

{
  "criterion_id": "no_contraindication",
  "criterion_label": "No seizure history or ferromagnetic implants",
  "policy_citation": "FDA label",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "no_contraindication",
  "status": "met",
  "excerpt": "No seizure history. No intracranial metal, cochlear implant, or other ferromagnetic device.",
  "sourceDocument": "Pre-TMS Screen 2026-04-15",
  "confidence": 1
}

chart.extract_evidence·361ms14:30:00.786

›Input

{
  "criterion_id": "phq9",
  "criterion_label": "PHQ-9 ≥15 (moderate-severe)",
  "policy_citation": "Optum BH-005 §A.5",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "phq9",
  "status": "met",
  "excerpt": "PHQ-9: 22 (2026-04-15). Prior PHQ-9: 19 (2025-12-10), 21 (2025-09-04).",
  "sourceDocument": "Validated assessment",
  "confidence": 1
}

Output

{
  "metCount": 5,
  "partialCount": 0,
  "missingCount": 0,
  "avgConfidence": 0.982
}

Modelclaude-opus-4-7@20260318

Promptauthora-evx-4.7.2

Statuscompleted

04CMS-0057-F Compliance158ms·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·69ms14:30:01.287
›Input
{ "urgency": "routine", "slaWindowHours": 168, "payerId": "uhc" }
›Output
{ "compliant": true, "marginHours": 164 }
compliance.check_denial_reason_specificity·49ms14:30:01.356
›Input
{ "policyId": "uhc-tms-2026" }
›Output
{ "specificityScore": 1, "requiredFieldsCovered": [ "criterionRef", "evidenceGap", "remediation", "appealPath" ] }
compliance.public_reporting_fields·40ms14:30:01.405
›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

05Submission1.32s·720 / 360 tok·$0.0020

Thinking

Bundle profile-validated. Transmission acknowledged by UHC. 278/13 response parsed (HCR01=A1).

Tool calls (3)

fhir.build_pas_bundle·214ms14:30:01.445

›Input

{
  "caseNumber": "AUT-2026-00193",
  "profile": "davinci-pas-2.1",
  "validate": true
}

›Output

{
  "bundleId": "pas-request-AUT-2026-00193",
  "profileConformance": "valid",
  "entryCount": 6
}

payer.transmit·1.00s14:30:01.659

›Input

{
  "endpoint": "https://developer.uhc.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00193"
}

›Output

{
  "ack": "received",
  "correlationId": "UHC-151903"
}

x12.parse_278_response·105ms14:30:02.661

›Input

{
  "format": "005010X216",
  "correlationId": "UHC-151903"
}

›Output

{
  "hcr01": "A1",
  "authNumber": "UHC-2026-119477",
  "authPeriod": {
    "start": "2026-05-15",
    "end": "2026-09-15"
  }
}

Output

{
  "bundleId": "pas-request-AUT-2026-00193",
  "hcr01": "A1",
  "authNumber": "UHC-2026-119477"
}

Modelclaude-haiku-4-5@20251001

Promptauthora-sub-2.2.0

Statuscompleted

06Notification286ms·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·154ms14:30:02.766

›Input

{
  "caseNumber": "AUT-2026-00193",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}

›Output

{
  "message": "Hi Emeka — your Transcranial Magnetic Stimulation — 36-session course has been approved. The imaging center will reach out to schedule.",
  "length": 132,
  "channel": "sms"
}

ehr.draft_inbasket_message·132ms14:30:02.920

›Input

{
  "caseNumber": "AUT-2026-00193",
  "recipientNpi": "1456789012",
  "urgency": "routine"
}

›Output

{
  "recipient": "Dr. Franco",
  "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