Skip to content
AUT-2026-00195

Cardiac MRI with stress perfusion

Aiko Ito · 52F · Anthem · Anthem Blue PPO

Appeal overturnedPrint authorization letter
Patient
NameAiko Ito
DOBDec 2, 1973 · age 52
MRNMRN-014557
Member IDANTH-330887119
StateCA
PlanAnthem Blue PPO
Ordering provider
NameMarcos Garcia, MD
NPI1922088901
SpecialtyCardiology
OrganizationPacific Heart Specialists
Order
CPT
75561
ICD-10
I25.10R94.31
Service dateMay 13, 2026
UrgencyRoutine
Est. cost$2,950
Clinical narrative
52F with prior CABG, atypical chest pain, indeterminate stress nuclear study. Cardiologist ordering cardiac MRI with stress perfusion to evaluate viability and ischemia in graft territories.
Evidence: 5 source documents
  • ·Cardiology Note 2026-04-25
  • ·Med list + nuclear stress report
  • ·Imaging history
  • ·NPPES verification
Criteria evaluation
Anthem Medical Policy RAD.00029

Magnetic Resonance Imaging — Lumbar Spine

5 met · 0 partial · 0 missing · 5 total
Symptom duration ≥6 weeks OR red-flag symptoms present
Met
“Atypical chest discomfort x 6 weeks; nuclear stress 2026-04-12 indeterminate.”
Cardiology Note 2026-04-25
confidence 0.92
Citation: Anthem RAD.00029 §III.A.1
Failed conservative therapy (unless red flags)
Met
“Optimized medical therapy on board. Nuclear stress already attempted; indeterminate.”
Med list + nuclear stress report
confidence 0.94
Citation: Anthem RAD.00029 §III.A.2
Focal neuro findings on exam OR surgical/injection planning
Met
“EKG: nonspecific ST-T changes; troponin negative. Cardiologist seeking definitive viability assessment.”
Cardiology Note 2026-04-25
confidence 0.91
Citation: Anthem RAD.00029 §III.A.3
No equivalent imaging within 12 months
Met
“No prior cardiac MRI on record.”
Imaging history
confidence 1.00
Citation: Anthem RAD.00029 §III.A.4
Ordered by credentialed provider
Met
“Board-certified cardiologist, NPI on file, active CA license.”
NPPES verification
confidence 1.00
Citation: Anthem RAD.00029 §II
Decision
Approved
Auth #ANTH-2026-99887-APPEAL · May 13, 2026 → Aug 13, 2026
Initial reviewer cited 'alternative imaging' as missing; appeal demonstrated nuclear stress was inconclusive and ACC AUC supports MRI as next step. Approved.
Decided by Anthem Appeals Panel · Appeal panel2h ago
Agent trace · run run_aut-2026-00195_58606

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 duration3.02s
Agents6
Total tokens5,238 in · 2,386 out
Total cost$0.1415
  1. 01Patient Context602ms·494 / 269 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·212ms14:30:00.000
    ›Input
    {
  "resourceType": "Patient",
  "identifier": "MRN-014557"
}
    ›Output 
    {
  "id": "pt-ito",
  "name": "Ito, Aiko",
  "birthDate": "1973-12-02",
  "gender": "female",
  "address": {
    "state": "CA",
    "country": "US"
  }
}
    fhir.search_coverage·156ms14:30:00.212
    ›Input
    {
  "patient": "pt-ito",
  "status": "active"
}
    ›Output 
    {
  "coverage": {
    "id": "cov-pt-ito",
    "payor": "Anthem (Elevance Health)",
    "plan": "Anthem Blue PPO",
    "subscriberId": "ANTH-330887119",
    "status": "active"
  }
}
    fhir.search_encounter·234ms14:30:00.368
    ›Input
    {
  "patient": "pt-ito",
  "_count": 5,
  "_sort": "-date"
}
    ›Output 
    {
  "encounters": [
    {
      "id": "enc-duration",
      "type": "AMB",
      "source": "Cardiology Note 2026-04-25"
    },
    {
      "id": "enc-conservative_care",
      "type": "AMB",
      "source": "Med list + nuclear stress report"
    },
    {
      "id": "enc-exam_findings",
      "type": "AMB",
      "source": "Cardiology Note 2026-04-25"
    },
    {
      "id": "enc-no_recent_imaging",
      "type": "AMB",
      "source": "Imaging history"
    }
  ]
}
    Output
    {
  "patientId": "pt-ito",
  "coverageId": "cov-pt-ito",
  "recentEncounterCount": 4,
  "ageAtService": 52
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pcx-2.4.1
    Statuscompleted
  2. 02Policy Match281ms·334 / 217 tok·$0.0011
    Thinking
    Single high-confidence match: Magnetic Resonance Imaging — Lumbar Spine. 5 criteria current as of 2026-03-15.
    Tool calls (2)
    policy_index.lookup·108ms14:30:00.602
    ›Input
    {
  "payerId": "anthem",
  "cpt": "75561",
  "plan": "Anthem Blue PPO"
}
    ›Output 
    {
  "policyId": "anthem-lumbar-mri-2026",
  "citation": "Anthem Medical Policy RAD.00029",
  "effectiveDate": "2026-01-01"
}
    policy_index.fetch_criteria·173ms14:30:00.710
    ›Input
    {
  "policyId": "anthem-lumbar-mri-2026",
  "version": "2026-03-15"
}
    ›Output 
    {
  "criteriaCount": 5,
  "criteria": [
    {
      "id": "duration",
      "label": "Symptom duration ≥6 weeks OR red-flag symptoms present",
      "source": "PayerPolicy"
    },
    {
      "id": "conservative_care",
      "label": "Failed conservative therapy (unless red flags)",
      "source": "PayerPolicy"
    },
    {
      "id": "exam_findings",
      "label": "Focal neuro findings on exam OR surgical/injection planning",
      "source": "PayerPolicy"
    },
    {
      "id": "no_recent_imaging",
      "label": "No equivalent imaging within 12 months",
      "source": "PayerPolicy"
    },
    {
      "id": "ordered_by_credentialed",
      "label": "Ordered by credentialed provider",
      "source": "PayerPolicy"
    }
  ]
}
    Output
    {
  "policyId": "anthem-lumbar-mri-2026",
  "criteriaCount": 5
}
    Modelclaude-haiku-4-5@20251001
    Promptauthora-pmt-3.1.0
    Statuscompleted
  3. 03Evidence Extraction470ms·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·333ms14:30:00.922
    ›Input
    {
  "criterion_id": "duration",
  "criterion_label": "Symptom duration ≥6 weeks OR red-flag symptoms present",
  "policy_citation": "Anthem RAD.00029 §III.A.1",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "duration",
  "status": "met",
  "excerpt": "Atypical chest discomfort x 6 weeks; nuclear stress 2026-04-12 indeterminate.",
  "sourceDocument": "Cardiology Note 2026-04-25",
  "confidence": 0.92
}
    chart.extract_evidence·320ms14:30:00.920
    ›Input
    {
  "criterion_id": "conservative_care",
  "criterion_label": "Failed conservative therapy (unless red flags)",
  "policy_citation": "Anthem RAD.00029 §III.A.2",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "conservative_care",
  "status": "met",
  "excerpt": "Optimized medical therapy on board. Nuclear stress already attempted; indeterminate.",
  "sourceDocument": "Med list + nuclear stress report",
  "confidence": 0.94
}
    chart.extract_evidence·390ms14:30:00.936
    ›Input
    {
  "criterion_id": "exam_findings",
  "criterion_label": "Focal neuro findings on exam OR surgical/injection planning",
  "policy_citation": "Anthem RAD.00029 §III.A.3",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "exam_findings",
  "status": "met",
  "excerpt": "EKG: nonspecific ST-T changes; troponin negative. Cardiologist seeking definitive viability assessment.",
  "sourceDocument": "Cardiology Note 2026-04-25",
  "confidence": 0.91
}
    chart.extract_evidence·446ms14:30:00.907
    ›Input
    {
  "criterion_id": "no_recent_imaging",
  "criterion_label": "No equivalent imaging within 12 months",
  "policy_citation": "Anthem RAD.00029 §III.A.4",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "no_recent_imaging",
  "status": "met",
  "excerpt": "No prior cardiac MRI on record.",
  "sourceDocument": "Imaging history",
  "confidence": 1
}
    chart.extract_evidence·370ms14:30:00.901
    ›Input
    {
  "criterion_id": "ordered_by_credentialed",
  "criterion_label": "Ordered by credentialed provider",
  "policy_citation": "Anthem RAD.00029 §II",
  "fhir_resources": [
    "Encounter",
    "Condition",
    "MedicationRequest",
    "DocumentReference",
    "Observation"
  ]
}
    ›Output 
    {
  "criterionId": "ordered_by_credentialed",
  "status": "met",
  "excerpt": "Board-certified cardiologist, NPI on file, active CA license.",
  "sourceDocument": "NPPES verification",
  "confidence": 1
}
    Output
    {
  "metCount": 5,
  "partialCount": 0,
  "missingCount": 0,
  "avgConfidence": 0.954
}
    Modelclaude-opus-4-7@20260318
    Promptauthora-evx-4.7.2
    Statuscompleted
  4. 04CMS-0057-F Compliance145ms·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·62ms14:30:01.353
    ›Input
    {
  "urgency": "routine",
  "slaWindowHours": 168,
  "payerId": "anthem"
}
    ›Output 
    {
  "compliant": true,
  "marginHours": 164
}
    compliance.check_denial_reason_specificity·41ms14:30:01.415
    ›Input
    {
  "policyId": "anthem-lumbar-mri-2026"
}
    ›Output 
    {
  "specificityScore": 1,
  "requiredFieldsCovered": [
    "criterionRef",
    "evidenceGap",
    "remediation",
    "appealPath"
  ]
}
    compliance.public_reporting_fields·42ms14:30:01.456
    ›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. 05Submission1.26s·720 / 360 tok·$0.0020
    Thinking
    Bundle profile-validated. Transmission acknowledged by Anthem. 278/13 response parsed (HCR01=A1).
    Tool calls (3)
    fhir.build_pas_bundle·205ms14:30:01.498
    ›Input
    {
  "caseNumber": "AUT-2026-00195",
  "profile": "davinci-pas-2.1",
  "validate": true
}
    ›Output 
    {
  "bundleId": "pas-request-AUT-2026-00195",
  "profileConformance": "valid",
  "entryCount": 6
}
    payer.transmit·938ms14:30:01.703
    ›Input
    {
  "endpoint": "https://api.anthem.com/fhir/r4",
  "method": "POST",
  "contentType": "application/fhir+json",
  "bundleId": "pas-request-AUT-2026-00195"
}
    ›Output 
    {
  "ack": "received",
  "correlationId": "ANTHEM-959170"
}
    x12.parse_278_response·117ms14:30:02.641
    ›Input
    {
  "format": "005010X216",
  "correlationId": "ANTHEM-959170"
}
    ›Output 
    {
  "hcr01": "A1",
  "authNumber": "ANTH-2026-99887-APPEAL",
  "authPeriod": {
    "start": "2026-05-13",
    "end": "2026-08-13"
  }
}
    Output
    {
  "bundleId": "pas-request-AUT-2026-00195",
  "hcr01": "A1",
  "authNumber": "ANTH-2026-99887-APPEAL"
}
    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·154ms14:30:02.758
    ›Input
    {
  "caseNumber": "AUT-2026-00195",
  "channel": "sms",
  "reading_level": "grade_8",
  "language": "en"
}
    ›Output 
    {
  "message": "Hi Aiko — your Cardiac MRI with stress perfusion has been approved. The imaging center will reach out to schedule.",
  "length": 132,
  "channel": "sms"
}
    ehr.draft_inbasket_message·107ms14:30:02.912
    ›Input
    {
  "caseNumber": "AUT-2026-00195",
  "recipientNpi": "1922088901",
  "urgency": "routine"
}
    ›Output 
    {
  "recipient": "Dr. Garcia",
  "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