Medical necessity failure on one order

Score

72.0

Partial · 2m 43s

Criteria

Extracted both orders accurately0.8

Linked CPT 74178 to ICD I10 from referral text but did not flag the transcription note in the clinical-notes section.

Correctly split into accept + per-order return1.0

ORM^O01 for accepted order structurally valid1.0

Return reason matches expected vocabulary0.5

Return reason emitted as "out_of_scope_procedure" rather than "med_nec_failed".

No ORM^O01 emitted for rejected order1.0

Patient

Diane Kowalski, 54F

MRN

MRN-MC-00101

Referrer

Dr. Rachel Nguyen (NPI 1326842108)

Payer

Blue Shield of California

Order 1

CPT 70553 — MRI brain / ICD G43.909 (accept)

Order 2

CPT 74178 — CT abd/pelvis / ICD I10 (med-nec fail)

Decision

Mixed · 1 ORM^O01, 1 per-order return

Changes made by agent

HL7 Interface—→1 × ORM^O01 accepted (MSG-4507) for CPT 70553

SFTP Outbox—→Per-order return sidecar for CPT 74178 (med_nec_failed)

Agent Activity

0:00

Fetched + OCR multi-order PDF

Extracted two orders; clinical notes flag possible ICD transcription error on second order.

0:40

Applied medical-necessity policy

Order 1 (MRI brain ↔ migraine) passes. Order 2 (CT abd/pelvis ↔ essential hypertension) fails med-nec under imaging policy.

1:32

Emitted ORM^O01 for accepted order

PID/ORC/OBR for CPT 70553 sent; AA ACK received.

2:18

Wrote per-order return

Created per-order return sidecar for CPT 74178 with reason "med_nec_failed".