Outbound response

{
  "resourceType": "ClaimResponse",
  "id": "claimresponse-CASE-1004",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional"
      }
    ]
  },
  "use": "preauthorization",
  "patient": {
    "display": "T. Nguyen (SYNTHETIC)"
  },
  "created": "2026-07-14T23:08:05+00:00",
  "outcome": "queued",
  "disposition": "Pended \u2014 clinical review",
  "item": [
    {
      "itemSequence": 1,
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible"
              }
            ]
          },
          "reason": {
            "text": "This request does not currently meet medical-necessity criteria. The patient has only 6 days of mild, improving, non-radicular low back pain, failing the duration requirement [C4], and has not undergone any conservative therapy trial [C1], with no evidence of persistent or worsening symptoms [C2]. A focused neurological exam was performed and is entirely normal [C3], and no red-flag conditions such as cauda equina syndrome, progressive motor deficit, malignancy, or trauma are present [C5], so the conservative-therapy and duration requirements are not waived. The ordering provider explicitly notes that imaging is not expected to alter management [C6], and the request appears driven by patient reassurance rather than clinical indication. Based on the chart as documented, this does not meet the payer's medical-necessity criteria for MRI lumbar spine without contrast; a course of conservative management with reassessment is recommended before imaging is considered."
          }
        }
      ],
      "extension": [
        {
          "url": "https://threadmaze.example/review-action",
          "valueString": "pended"
        }
      ],
      "productOrService": {
        "coding": [
          {
            "system": "https://www.ama-assn.org/go/cpt",
            "code": "72148"
          }
        ],
        "text": "MRI lumbar spine without contrast (CPT 72148)"
      }
    }
  ],
  "processNote": [
    {
      "number": 1,
      "type": "display",
      "text": "This request does not currently meet medical-necessity criteria. The patient has only 6 days of mild, improving, non-radicular low back pain, failing the duration requirement [C4], and has not undergone any conservative therapy trial [C1], with no evidence of persistent or worsening symptoms [C2]. A focused neurological exam was performed and is entirely normal [C3], and no red-flag conditions such as cauda equina syndrome, progressive motor deficit, malignancy, or trauma are present [C5], so the conservative-therapy and duration requirements are not waived. The ordering provider explicitly notes that imaging is not expected to alter management [C6], and the request appears driven by patient reassurance rather than clinical indication. Based on the chart as documented, this does not meet the payer's medical-necessity criteria for MRI lumbar spine without contrast; a course of conservative management with reassessment is recommended before imaging is considered."
    }
  ],
  "_note": "SYNTHETIC \u2014 illustrative FHIR PAS ClaimResponse for a portfolio demo."
}

// SYNTHETIC X12 278 response — illustrative segments only, not a valid ISA/GS/ST envelope.
ST*278*0001*005010X217~
BHT*0007*11*CASE-1004*20260715~
HL*1**20*1~   // Utilization Management Organization (payer/TPA)
HL*2*1*21*1~  // Requester (ordering provider)
HL*3*2*22*0~  // Subscriber / member
UM*HS*I*72148~  // service reviewed
HCR*A4*AUTH-001004~  // decision: Pended
MSG*This request does not currently meet medical-necessity criteria. The patient has only 6 days of mild, improving, non-radicular low back pain, failing the duration requirement [C4], and has not undergone any conservative therapy trial [C1], with no ev~  // cited clinical rationale
SE*9*0001~