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CASE-1006

Meridian Medicare Advantage · MRI lumbar spine without contrast (CPT 72148)

standard · 7d Nurse review low confidence

Engine recommendation

low confidence

Insufficient documentation

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

✓ 0 met ✕ 0 not met 📎 0/0 grounded

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

Why (full reasoning)

The automated adjudication engine returned no result; routed for manual review.

Criteria checklist

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

No structured criteria (engine error → manual review).

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

Automated review unavailable — manual review required.

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 2026-07-21 13:08 UTC

Case facts

Member: A. Ford (SYNTHETIC)
DOB: 1970-01-01
CPT: 72148
Diagnosis: Lumbar radiculopathy (left L5)
ICD-10: M54.16
Received: 2026-07-14 13:08

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.