AUT-2026-00194

Dexcom G7 CGM + supplies (90-day)

Walter Hartman · 76M · Humana · Humana Medicare Advantage Choice

In review

Patient

NameWalter Hartman

DOBMar 25, 1949 · age 76

MRNMRN-013884

Member IDHUM-901224756

StateFL

PlanHumana Medicare Advantage Choice

Ordering provider

NameChinedu Okonkwo, MD

NPI1689345712

SpecialtyInternal Medicine

OrganizationOakwood Primary Care

Order

CPT

—

ICD-10

E11.65E16.2

Service dateMay 10, 2026

UrgencyRoutine

Est. cost$720

Clinical narrative

76M with T2DM on basal-bolus insulin (lantus 30u QHS, novolog with meals). Two episodes of severe hypoglycemia in last 6 months requiring glucagon. PCP requesting CGM for safety.

Evidence: 4 source documents

·Progress Notes 2026-02-14, 2026-03-22, 2026-04-30
·Care Team Roster
·Encounter 2026-04-30
·Care Plan 2026-04-30

Criteria evaluation

CMS LCD L33822 + Humana Coverage Policy

Continuous Glucose Monitor (CGM) — Therapeutic

3 met · 1 partial · 0 missing · 4 total

T1DM OR T2DM on insulin OR T2DM with severe hypoglycemia

Met

“T2DM on insulin (lantus + novolog). Two severe hypoglycemic events documented (2026-02-14, 2026-03-22).”

Progress Notes 2026-02-14, 2026-03-22, 2026-04-30

confidence 0.99

Citation: CMS LCD L33822 §A.1

Managed by treating practitioner

Met

“Dr. Okonkwo, PCP — managing diabetes regimen for past 4 years.”

Care Team Roster

confidence 0.97

Citation: CMS LCD L33822 §A.2

Visit within 6 months establishing need

Met

“In-person visit 2026-04-30; A1c 7.8; medication review.”

Encounter 2026-04-30

confidence 1.00

Citation: CMS LCD L33822 §A.3

Patient/caregiver trained on device

Partial

“CGM training scheduled with Dexcom on insertion; CDE consult to be scheduled. Documentation pending.”

Care Plan 2026-04-30

confidence 0.65

Citation: CMS LCD L33822 §A.4

Ready to submit

Submit to Humana

Authora will package a Da Vinci PAS request bundle, transmit to Humana, and deliver the X12 278 response back into this case.

· 0 CPT code(s), 2 diagnosis code(s)
· 4 evidence elements attached
· Policy: CMS LCD L33822 + Humana Coverage Policy

Submission timeline

30 min agoPayer
Humana auto-bot requested CDE consult confirmation
Humana
6h agoSystem
Submitted to Humana
6h agoProvider
CGM DME PA initiated
Dr. Okonkwo
6h agoAI
3 of 4 met; education partial (training scheduled)

Wire format

{
  "resourceType": "Bundle",
  "id": "pas-request-AUT-2026-00194",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"
    ]
  },
  "type": "collection",
  "timestamp": "2026-05-31T21:44:13.701Z",
  "entry": [
    {
      "fullUrl": "urn:uuid:e3104acd-4908-4e98-b4b6-7c7c92211fa6",
      "resource": {
        "resourceType": "Claim",
        "id": "e3104acd-4908-4e98-b4b6-7c7c92211fa6",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
          ]
        },
        "identifier": [
          {
            "system": "https://authora.health/cases",
            "value": "AUT-2026-00194"
          }
        ],
        "status": "active",
        "type": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/claim-type",
              "code": "institutional"
            }
          ]
        },
        "use": "preauthorization",
        "patient": {
          "reference": "urn:uuid:8d0b4b1b-37d5-401b-99a0-d18a257abd07"
        },
        "created": "2026-05-08T08:30:00.000Z",
        "insurer": {
          "reference": "urn:uuid:6248939e-cd9e-42c3-8f05-82e5f35326b4"
        },
        "provider": {
          "reference": "urn:uuid:81ab8771-5e38-4419-914a-4bffc2c04087"
        },
        "priority": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/processpriority",
              "code": "normal"
            }
          ]
        },
        "careTeam": [
          {
            "sequence": 1,
            "provider": {
              "reference": "urn:uuid:4faee2de-2b71-4b48-b813-7aa6b79c8a1f"
            },
            "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": "E11.65",
                  "display": "Type 2 diabetes mellitus with hyperglycemia"
                }
              ]
            }
          },
          {
            "sequence": 2,
            "diagnosisCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/sid/icd-10-cm",
                  "code": "E16.2",
                  "display": "Hypoglycemia, unspecified"
                }
              ]
            }
          }
        ],
        "insurance": [
          {
            "sequence": 1,
            "focal": true,
            "coverage": {
              "reference": "urn:uuid:b45244b5-5aa9-4fc9-a286-a6c8b1ad514c"
            }
          }
        ],
        "item": []
      }
    },
    {
      "fullUrl": "urn:uuid:8d0b4b1b-37d5-401b-99a0-d18a257abd07",
      "resource": {
        "resourceType": "Patient",
        "id": "8d0b4b1b-37d5-401b-99a0-d18a257abd07",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-mbi",
            "value": "HUM-901224756"
          },
          {
            "system": "https://authora.health/mrn",
            "value": "MRN-013884"
          }
        ],
        "name": [
          {
            "family": "Hartman",
            "given": [
              "Walter"
            ]
          }
        ],
        "gender": "male",
        "birthDate": "1949-03-25",
        "address": [
          {
            "state": "FL",
            "country": "US"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:b45244b5-5aa9-4fc9-a286-a6c8b1ad514c",
      "resource": {
        "resourceType": "Coverage",
        "id": "b45244b5-5aa9-4fc9-a286-a6c8b1ad514c",
        "status": "active",
        "subscriberId": "HUM-901224756",
        "beneficiary": {
          "reference": "urn:uuid:8d0b4b1b-37d5-401b-99a0-d18a257abd07"
        },
        "payor": [
          {
            "reference": "urn:uuid:6248939e-cd9e-42c3-8f05-82e5f35326b4"
          }
        ],
        "class": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "plan"
                }
              ]
            },
            "value": "Humana Medicare Advantage Choice"
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:6248939e-cd9e-42c3-8f05-82e5f35326b4",
      "resource": {
        "resourceType": "Organization",
        "id": "6248939e-cd9e-42c3-8f05-82e5f35326b4",
        "identifier": [
          {
            "system": "https://hl7.org/fhir/sid/us-payer",
            "value": "humana"
          }
        ],
        "name": "Humana",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/organization-type",
                "code": "ins"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:81ab8771-5e38-4419-914a-4bffc2c04087",
      "resource": {
        "resourceType": "Organization",
        "id": "81ab8771-5e38-4419-914a-4bffc2c04087",
        "name": "Oakwood Primary Care",
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/organization-type",
                "code": "prov"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl": "urn:uuid:4faee2de-2b71-4b48-b813-7aa6b79c8a1f",
      "resource": {
        "resourceType": "Practitioner",
        "id": "4faee2de-2b71-4b48-b813-7aa6b79c8a1f",
        "identifier": [
          {
            "system": "http://hl7.org/fhir/sid/us-npi",
            "value": "1689345712"
          }
        ],
        "name": [
          {
            "family": "Okonkwo",
            "given": [
              "Chinedu"
            ],
            "suffix": [
              "MD"
            ]
          }
        ]
      }
    }
  ]
}

Payer connection

Humana

PARDD live

CRD

DTR

PAS

Agent trace · run run_aut-2026-00194_73706

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 duration2.85s

Agents6

Total tokens5,097 in · 2,137 out

Total cost$0.1245

01Patient Context548ms·559 / 220 tok·$0.0013

Thinking

Patient on active commercial coverage. Recent encounters cover the relevant clinical window. Demographics consistent with order.

Tool calls (3)

fhir.read_patient·171ms08:30:00.000

›Input

{
  "resourceType": "Patient",
  "identifier": "MRN-013884"
}

›Output

{
  "id": "pt-hartman",
  "name": "Hartman, Walter",
  "birthDate": "1949-03-25",
  "gender": "male",
  "address": {
    "state": "FL",
    "country": "US"
  }
}

fhir.search_coverage·122ms08:30:00.171

›Input

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

›Output

{
  "coverage": {
    "id": "cov-pt-hartman",
    "payor": "Humana",
    "plan": "Humana Medicare Advantage Choice",
    "subscriberId": "HUM-901224756",
    "status": "active"
  }
}

fhir.search_encounter·255ms08:30:00.293

›Input

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

›Output

{
  "encounters": [
    {
      "id": "enc-diagnosis",
      "type": "AMB",
      "source": "Progress Notes 2026-02-14, 2026-03-22, 2026-04-30"
    },
    {
      "id": "enc-managed_by_pcp",
      "type": "AMB",
      "source": "Care Team Roster"
    },
    {
      "id": "enc-visit_6mo",
      "type": "AMB",
      "source": "Encounter 2026-04-30"
    },
    {
      "id": "enc-education",
      "type": "AMB",
      "source": "Care Plan 2026-04-30"
    }
  ]
}

Output

{
  "patientId": "pt-hartman",
  "coverageId": "cov-pt-hartman",
  "recentEncounterCount": 4,
  "ageAtService": 76
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pcx-2.4.1

Statuscompleted

02Policy Match261ms·348 / 197 tok·$0.0011

Thinking

Single high-confidence match: Continuous Glucose Monitor (CGM) — Therapeutic. 4 criteria current as of 2026-02-15.

Tool calls (2)

policy_index.lookup·94ms08:30:00.548

›Input

{
  "payerId": "humana",
  "plan": "Humana Medicare Advantage Choice"
}

›Output

{
  "policyId": "humana-cgm-2026",
  "citation": "CMS LCD L33822 + Humana Coverage Policy",
  "effectiveDate": "2026-01-01"
}

policy_index.fetch_criteria·167ms08:30:00.642

›Input

{
  "policyId": "humana-cgm-2026",
  "version": "2026-02-15"
}

›Output

{
  "criteriaCount": 4,
  "criteria": [
    {
      "id": "diagnosis",
      "label": "T1DM OR T2DM on insulin OR T2DM with severe hypoglycemia",
      "source": "CMS_LCD"
    },
    {
      "id": "managed_by_pcp",
      "label": "Managed by treating practitioner",
      "source": "CMS_LCD"
    },
    {
      "id": "visit_6mo",
      "label": "Visit within 6 months establishing need",
      "source": "CMS_LCD"
    },
    {
      "id": "education",
      "label": "Patient/caregiver trained on device",
      "source": "CMS_LCD"
    }
  ]
}

Output

{
  "policyId": "humana-cgm-2026",
  "criteriaCount": 4
}

Modelclaude-haiku-4-5@20251001

Promptauthora-pmt-3.1.0

Statuscompleted

03Evidence Extraction551ms·2,680 / 1,040 tok·$0.1182

Thinking

Fanned out 4 parallel extract_evidence calls against chart resources. Each criterion returns a quoted excerpt with source provenance and a confidence score. Met=3, partial=1, missing=0.

Tool calls (4)

chart.extract_evidence·422ms08:30:00.841

›Input

{
  "criterion_id": "diagnosis",
  "criterion_label": "T1DM OR T2DM on insulin OR T2DM with severe hypoglycemia",
  "policy_citation": "CMS LCD L33822 §A.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "diagnosis",
  "status": "met",
  "excerpt": "T2DM on insulin (lantus + novolog). Two severe hypoglycemic events documented (2026-02-14, 2026-03-22).",
  "sourceDocument": "Progress Notes 2026-02-14, 2026-03-22, 2026-04-30",
  "confidence": 0.99
}

chart.extract_evidence·431ms08:30:00.811

›Input

{
  "criterion_id": "managed_by_pcp",
  "criterion_label": "Managed by treating practitioner",
  "policy_citation": "CMS LCD L33822 §A.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "managed_by_pcp",
  "status": "met",
  "excerpt": "Dr. Okonkwo, PCP — managing diabetes regimen for past 4 years.",
  "sourceDocument": "Care Team Roster",
  "confidence": 0.97
}

chart.extract_evidence·373ms08:30:00.842

›Input

{
  "criterion_id": "visit_6mo",
  "criterion_label": "Visit within 6 months establishing need",
  "policy_citation": "CMS LCD L33822 §A.3",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "visit_6mo",
  "status": "met",
  "excerpt": "In-person visit 2026-04-30; A1c 7.8; medication review.",
  "sourceDocument": "Encounter 2026-04-30",
  "confidence": 1
}

chart.extract_evidence·510ms08:30:00.850

›Input

{
  "criterion_id": "education",
  "criterion_label": "Patient/caregiver trained on device",
  "policy_citation": "CMS LCD L33822 §A.4",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}

›Output

{
  "criterionId": "education",
  "status": "partial",
  "excerpt": "CGM training scheduled with Dexcom on insertion; CDE consult to be scheduled. Documentation pending.",
  "sourceDocument": "Care Plan 2026-04-30",
  "confidence": 0.65
}

Output

{
  "metCount": 3,
  "partialCount": 1,
  "missingCount": 0,
  "avgConfidence": 0.902
}

Notes

·1 criterion partially evidenced — chart extraction suggests resubmittable with one additional artifact.

Modelclaude-opus-4-7@20260318

Promptauthora-evx-4.7.2

Statuscompleted

04CMS-0057-F Compliance153ms·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·69ms08:30:01.360
›Input
{ "urgency": "routine", "slaWindowHours": 168, "payerId": "humana" }
›Output
{ "compliant": true, "marginHours": 164 }
compliance.check_denial_reason_specificity·46ms08:30:01.429
›Input
{ "policyId": "humana-cgm-2026" }
›Output
{ "specificityScore": 1, "requiredFieldsCovered": [ "criterionRef", "evidenceGap", "remediation", "appealPath" ] }
compliance.public_reporting_fields·38ms08:30:01.475
›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

05Submission1.04s·720 / 360 tok·$0.0020

Thinking

Bundle profile-validated. Transmission acknowledged by Humana. 278/13 response parsed (HCR01=A4).

Tool calls (3)

fhir.build_pas_bundle·163ms08:30:01.513

›Input

{
  "caseNumber": "AUT-2026-00194",
  "profile": "davinci-pas-2.1",
  "validate": true
}

›Output

{
  "bundleId": "pas-request-AUT-2026-00194",
  "profileConformance": "valid",
  "entryCount": 6
}

payer.transmit·780ms08:30:01.676

›Input

{
  "endpoint": "https://developers.humana.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00194"
}

›Output

{
  "ack": "received",
  "correlationId": "HUMANA-957806"
}

x12.parse_278_response·96ms08:30:02.456

›Input

{
  "format": "005010X216",
  "correlationId": "HUMANA-957806"
}

›Output

{
  "hcr01": "A4",
  "authPeriod": {}
}

Output

{
  "bundleId": "pas-request-AUT-2026-00194",
  "hcr01": "A4",
  "authNumber": null
}

Modelclaude-haiku-4-5@20251001

Promptauthora-sub-2.2.0

Statuscompleted

06Notification299ms·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·170ms08:30:02.552

›Input

{
  "caseNumber": "AUT-2026-00194",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}

›Output

{
  "message": "Hi Walter — your Dexcom G7 CGM + supplies (90-day) request is moving through review. We'll text again as soon as there's an update.",
  "length": 138,
  "channel": "sms"
}

ehr.draft_inbasket_message·129ms08:30:02.722

›Input

{
  "caseNumber": "AUT-2026-00194",
  "recipientNpi": "1689345712",
  "urgency": "routine"
}

›Output

{
  "recipient": "Dr. Okonkwo",
  "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