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CASE-1001

Meridian Commercial PPO · MRI lumbar spine without contrast (CPT 72148)

standard · 7d Auto-approved high confidence

Engine recommendation

high confidence

Meets medical-policy criteria

Every required criterion is met and cited in the chart.

✓ 5 met ✕ 1 not met 📎 6/6 grounded

Why (full reasoning)

The patient meets all standard (non-red-flag) criteria for lumbar MRI without contrast. Conservative therapy was appropriately trialed and exceeded the required duration [C1], with symptoms persisting and progressing despite this treatment [C2]. A focused neurological exam supports a right L5 radiculopathy with objective motor and sensory findings [C3], and symptoms have been present for 10 weeks, satisfying the duration requirement [C4]. Although no red-flag features are documented (C5 not met, so C1/C4 are not waived but are independently satisfied), the requesting provider clearly states the MRI results will guide the choice between epidural steroid injection and surgical referral, satisfying the management-impact criterion [C6]. No additional documentation is required for approval based on the current chart.

Criteria checklist

Each medical-policy requirement, the engine's call, and the exact chart text it relied on.

✓ met Conservative therapy trial 📎 grounded

Cited evidence Physical therapy: 8 weeks, 2x/week (completed), documented in PT notes. NSAIDs: naproxen 500mg BID for 6 weeks.

Documented provider-directed PT for 8 weeks and NSAID therapy for 6 weeks exceeds the 6-week requirement.

✓ met Persistent/progressive symptoms despite conservative care 📎 grounded

Cited evidence Symptoms persist and have progressed despite the above.

Chart explicitly states symptoms persisted and worsened despite the conservative trial.

✓ met Focused neurological exam documented 📎 grounded

Cited evidence Motor: right extensor hallucis longus 4/5 (mild weakness); otherwise 5/5. Sensory: decreased sensation right L5 dermatome. Reflexes: symmetric 2+ patellar and Achilles.

Motor, sensory, and reflex findings are documented and support a radicular process (right L5).

✓ met Symptom duration ≥6 weeks 📎 grounded

Cited evidence 10 weeks of low back pain radiating down the right leg to the foot

Symptom duration of 10 weeks exceeds the 6-week minimum.

✕ not met Red flag present

Cited evidence No saddle anesthesia; no bowel/bladder dysfunction.

Chart explicitly documents absence of cauda equina red flags; no progressive motor deficit, trauma, infection, or malignancy history noted.

✓ met Impact on management 📎 grounded

Cited evidence MRI requested to evaluate for disc herniation / nerve root compression to guide possible epidural steroid injection vs surgical referral.

The requesting clinician states the MRI will directly inform choice between ESI and surgical referral.

Source chart the full submitted documentation — click to collapse

📄 PDF document

# Patient Chart — SYNTHETIC (fictional)
Patient: J. Doe (fictional) · Age 54 · MRN SYN-0001
Requested service: MRI lumbar spine without contrast (CPT 72148)

## History of Present Illness
54-year-old with 10 weeks of low back pain radiating down the right leg to the foot,
consistent with right L5 radiculopathy. Pain worsening over the last 3 weeks despite
treatment.

## Conservative treatment to date
- Physical therapy: 8 weeks, 2x/week (completed), documented in PT notes.
- NSAIDs: naproxen 500mg BID for 6 weeks.
- Activity modification counseled.
Symptoms persist and have progressed despite the above.

## Neurological exam
- Motor: right extensor hallucis longus 4/5 (mild weakness); otherwise 5/5.
- Sensory: decreased sensation right L5 dermatome.
- Reflexes: symmetric 2+ patellar and Achilles.
- No saddle anesthesia; no bowel/bladder dysfunction.

## Assessment / Plan
Right L5 radiculopathy, persistent despite conservative care. MRI requested to evaluate for
disc herniation / nerve root compression to guide possible epidural steroid injection vs
surgical referral.

Audit trail

engine clean approve The patient meets all standard (non-red-flag) criteria for lumbar MRI without contrast. Conservative therapy was appropriately trialed and exceeded the required duration [C1], with symptoms persisting and progressing despite this treatment [C2]. A focused neurological exam supports a right L5 radiculopathy with objective motor and sensory findings [C3], and symptoms have been present for 10 weeks, 2026-07-15 19:08

SLA remaining

…

due 2026-07-22 19:08 UTC

Case facts

Member: J. Doe (SYNTHETIC)
DOB: 1970-01-01
CPT: 72148
Diagnosis: Lumbar radiculopathy (right L5)
ICD-10: M54.16
Received: 2026-07-15 19:08

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Review & decide

Acting as coordinator. This role reviews only — switch to nurse or md to decide (you can still leave notes).

🔒 Synthetic data only — not for clinical use.