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CASE-1005

Meridian Medicaid MCO · MRI lumbar spine without contrast (CPT 72148)

standard · 7d Nurse review medium confidence

Engine recommendation

medium confidence

Insufficient documentation

The chart is missing evidence needed to decide — a request-info gap, not a denial.

✓ 5 met ✕ 2 not met 📎 6/6 grounded

Recommended next step Request info from the provider to close the documentation gap.

Why (full reasoning)

The patient meets the core commercial-baseline criteria: an adequate conservative therapy trial [C1] (8 weeks PT, 6 weeks NSAIDs) with persistent, progressive symptoms despite treatment [C2], a documented focused neurological exam showing mild L5 motor and sensory deficits [C3], symptom duration of 10 weeks exceeding the 6-week threshold [C4], and clear expected impact on management, as the MRI will guide a choice between epidural steroid injection and surgical referral [C6]. No red-flag criterion is substantiated in the chart [C5]: cauda equina findings are explicitly negative and the motor deficit, while present, is not documented as progressive, so C1, C4, and C7 are not waived. Because this plan requires a prior plain lumbar radiograph before advanced imaging is authorized, and no such radiograph or its result is documented anywhere in the chart [C7], the request cannot currently be approved. Authorization should be reconsidered once a plain X-ray of the lumbar spine has been obtained and its findings documented, or if the treating provider documents a red-flag finding (e.g., a clearly progressive motor deficit) that would waive C7.

Criteria checklist

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

✓ met Conservative therapy trial ≥6 weeks 📎 grounded

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

Documented PT and NSAID trial exceeding the 6-week threshold.

✓ met Persistent/progressive symptoms despite conservative trial 📎 grounded

Cited evidence Symptoms persist and have progressed despite the above.

Chart explicitly states progression despite conservative management.

✓ 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 exam findings are all documented.

✓ met Symptom duration ≥6 weeks 📎 grounded

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

Duration of 10 weeks exceeds the 6-week requirement.

✕ not met Red flag present (waives C1, C4, C7)

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

Chart explicitly negates cauda equina findings and documents only mild (4/5) stable weakness without stated progression, trauma, infection, or malignancy history, so no red flag criterion is substantiated.

✓ met Imaging expected to change 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 provider ties the MRI result directly to a management decision (injection vs. surgery).

✕ not met Prior plain lumbar radiograph performed and documented

No documentation of a plain lumbar-spine X-ray or its results appears anywhere in the chart.

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.

⚠ Missing documentation

Documentation of a prior plain lumbar-spine radiograph (X-ray) and its findings, as required by plan-specific C7
If a red flag is being asserted, explicit documentation of a progressive (worsening over time) motor deficit, or other red-flag finding (e.g., suspected infection, malignancy, cauda equina, trauma), since current exam shows only a single-point, non-progressive mild weakness with cauda equina symptoms explicitly denied

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 2026-07-22 09:08 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 09:08

View outbound response (FHIR / X12) →

Review & decide

Acting as nurse. May approve, request info, or escalate — never deny.

🔒 Synthetic data only — not for clinical use.