← Work queue

CASE-1002

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

standard · 7d Nurse review low confidence

Engine recommendation

low confidence

Does not meet criteria

One or more required criteria are not met in the submitted chart.

✓ 0 met ✕ 5 not met ? 1 unclear 📎 6/6 grounded

Recommended next step Escalate to a Medical Director — only an MD can deny.

Why (full reasoning)

The chart does not currently support medical necessity for lumbar MRI. Symptom duration is only 3 weeks, below the 6-week threshold in [C4], and no conservative therapy trial has been completed per [C1]—only same-day advice for rest and OTC ibuprofen was given, with no PT started. Because no red flag is documented ([C5] explicitly noted as absent), the conservative-therapy and duration requirements are not waived. Additionally, no neurological exam is documented ([C3]), and there is no evidence that imaging would alter management ([C6]); the request appears to be patient-driven rather than based on a failed conservative trial or radicular findings. Approval should be deferred pending completion of a guideline-concordant conservative therapy trial, a repeat visit documenting persistent or worsening symptoms, and a focused neurological exam, unless a red-flag condition emerges that would independently justify expedited imaging.

Criteria checklist

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

✕ not met Conservative therapy trial

Cited evidence Advised rest and over-the-counter ibuprofen at today's visit. No physical therapy started. No prior treatment documented.

Only same-day advice given, with no documented 6-week trial of provider-directed conservative management and no stated clinical reason to bypass it.

✕ not met Persistent/progressive symptoms despite conservative trial

Cited evidence 3 weeks of low back pain after moving furniture. Some discomfort radiating to the left buttock. No leg weakness or numbness reported.

No conservative trial has occurred yet, so persistence/progression despite treatment cannot be assessed.

✕ not met Neurological exam documented

Cited evidence Not documented at this visit.

No focused neurological exam (motor, sensation, reflexes) is present in the chart.

✕ not met Symptom duration ≥6 weeks

Cited evidence 3 weeks of low back pain after moving furniture.

Symptom duration is only 3 weeks, below the 6-week threshold, and no red flag is present to waive this requirement.

✕ not met Red-flag condition

Cited evidence No red-flag symptoms noted.

Chart explicitly states no red-flag symptoms are present, so C1/C4 are not waived.

? unclear Impact on management

Cited evidence Patient requests MRI.

No documentation indicates imaging is expected to change surgical or interventional management; request appears patient-driven rather than clinically indicated at this stage.

Source chart the full submitted documentation — click to collapse

📄 PDF document

# Patient Chart — SYNTHETIC (fictional)
Patient: R. Smith (fictional) · Age 41 · MRN SYN-0002
Requested service: MRI lumbar spine without contrast (CPT 72148)

## History of Present Illness
41-year-old with 3 weeks of low back pain after moving furniture. Some discomfort radiating
to the left buttock. No leg weakness or numbness reported.

## Conservative treatment to date
- Advised rest and over-the-counter ibuprofen at today's visit.
- No physical therapy started.
- No prior treatment documented.

## Neurological exam
- Not documented at this visit.

## Assessment / Plan
Acute low back pain, likely musculoskeletal. Patient requests MRI. No red-flag symptoms noted.

⚠ Missing documentation

Documented 6-week (or clinically appropriate alternative) trial of provider-directed conservative therapy (PT, NSAIDs, activity modification)
Follow-up documentation showing symptoms persist or worsen despite conservative treatment
Focused neurological exam (motor strength, sensation, reflexes)
Symptom duration ≥6 weeks or documentation of a red-flag condition (C5) to waive C1/C4
Clinical rationale for how MRI findings would change management (e.g., consideration of surgery or interventional referral)

These are what a provider could send to close the gap (a "Request Info" case, not a denial).

Audit trail

No human actions yet.

SLA remaining

…

due 2026-07-19 15:08 UTC

Case facts

Member: R. Smith (SYNTHETIC)
DOB: 1970-01-01
CPT: 72148
Diagnosis: Acute low back pain
ICD-10: M54.5
Received: 2026-07-12 15:08

View outbound response (FHIR / X12) →

Review & decide

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

🔒 Synthetic data only — not for clinical use.