T. Nguyen

Request PA-2026-04138 · 41 M · submitted 8/5/2026

📋 Request as submitted

Requested study

MRI lumbar spine without contrast

Urgency

standard

CPT72148

ICD-10M54.50 — Low back pain, unspecified

Ordering providerDr. K. Whitfield, Urgent Care (NPI 1740295861)

Site of serviceOutpatient imaging center

SLA — 7 day turnaround (CMS-0057-F)

Overdue

🩺 Clinical documentation

Office visit note — Dr. K. Whitfield, Urgent Care· 2026-08-05

Patient presents with low back pain, onset about 2 months ago per patient report. No documented red flag screening in the note — trauma history, neurologic symptoms, and constitutional symptoms are not addressed. No mention of any treatment tried to date. Physical exam limited to 'tenderness to palpation, lumbar paraspinal region.' Requesting MRI for further evaluation.

Submitted with the PA transaction, per the ordering provider — not a full inpatient chart. This is the documentation type a payer actually receives for an outpatient imaging request.

🤖 Agent analysis

Claude will extract the clinical facts from the note, identify the matching ACR Appropriateness Criteria procedure/variant, and return a determination with a criteria checklist and a CMS-0057-F specific-reason summary.

Criteria basis: ACR Appropriateness Criteria. This tool surfaces a recommendation for a human UM reviewer and does not auto-adjudicate.