CASE-003

An attempt that verification sent back is shown here in full: the system catching its own error is evidence, not something to hide. Attempt 3 was rejected, checked by gemini-3.5-flash.

1. Attempt 1 — Rejected by verification
   • fatal citation_accurate at NBH-CARD-014-3.5 — The source text does not require documentation to prove that *no* contraindication exists; it simply states that there is no contraindication, or if a relative contraindication exists, that the medical record documents it has been addressed.

     There is no contraindication to magnetic resonance imaging, or, where a relative contraindication exists, the medical record documents that it has been addressed.

2. Attempt 2 — Rejected by verification
   • fatal assertion_grounded at On April 22, 2026, the cardiologist documented that the cardiac MRI results will determine clinical management directly, leading to bone scintigraphy, serum free light chains, and disease-modifying therapy if positive for amyloid, or to invasive angiography if showing an ischaemic pattern of enhancement. — The chart evidence does not mention 'cardiac MRI' or state that cardiac MRI results will determine management; it only states that 'the distinction' determines management.

   Written to answer:

   • The source text does not require documentation to prove that *no* contraindication exists; it simply states that there is no contraindication, or if a relative contraindication exists, that the medical record documents it has been addressed.
   • The citation to NBH-CARD-014-3.5 misstates what that section says. Re-read the verbatim text and either restate it accurately or drop the point.
3. Attempt 3 — Rejected by verification
   • fatal citation_accurate at NBH-CARD-014-3.2 — The source text requires that the twelve-lead electrocardiogram and transthoracic echocardiogram be performed within the preceding twelve months, rather than requiring the entire initial diagnostic evaluation itself to be completed within that twelve-month period.

     An initial diagnostic evaluation has been completed and documented. This evaluation must include a twelve-lead electrocardiogram and a transthoracic echocardiogram performed within the twelve months preceding the request.

   Written to answer:

   • The chart evidence does not mention 'cardiac MRI' or state that cardiac MRI results will determine management; it only states that 'the distinction' determines management.
   • Remove or rephrase this assertion, which is not supported by any row in the criteria matrix: 'On April 22, 2026, the cardiologist documented that the cardiac MRI results will determine clinical management directly, leading to bone scintigraphy, serum free light chains, and disease-modifying therapy if positive for amyloid, or to invasive angiography if showing an ischaemic pattern of enhancement.'

The patient is an 83-year-old female presenting with progressive exertional dyspnoea. An initial evaluation including a 12-lead ECG and a transthoracic echocardiogram was completed in March 2026 but proved technically inadequate and inconclusive. The treating cardiologist requested a cardiac magnetic resonance imaging study with contrast to resolve the differential diagnosis between infiltrative cardiomyopathy and ischaemic heart disease, detailing how the results will directly guide subsequent clinical management, and addressing the patient's permanent pacemaker relative contraindication.

6 criteria could not be evaluated at all: NBH-CARD-014-5.1, NBH-CARD-014-5.2, NBH-CARD-014-5.3, NBH-CARD-014-6.1, NBH-CARD-014-6.2, NBH-CARD-014-6.3 Each was put to the model and came back without a verdict. That is a gap in what we know, not a criterion ruled irrelevant — a criterion written for a service other than the one denied gets its own not_applicable row above. Unevaluated rows count against the case: the basis for appealing is tested as though every one of them were unmet.

Payer

NORTHBECK HEALTH PLAN

Claim number

CLM-2026-0519-71144

Patient

Creola518 Heller342

Member id

NBH-4417-20551

Service denied

• Magnetic resonance imaging, cardiac, with contrast material, including stress imaging and morphology CPT/HCPCS 75561 · ICD-10 R06.00

Payer's stated reason

The clinical information submitted does not establish that cardiac magnetic resonance imaging is medically necessary under the plan's applicable medical policy. The submitted records do not establish that the initial diagnostic evaluation was inconclusive for the clinical question posed. The echocardiogram report dated March 9, 2026 provides an ejection fraction estimate and the reviewer determined that this constitutes an adequate assessment of left ventricular function. The reviewer further notes that the submitted records do not address whether a contraindication to magnetic resonance imaging exists.

Reason code NBH-NMN-11

Date of denial

2 June 2026

Appeal deadline

29 November 2026 · 30 days remaining

Appeal level

first level appeal

Last updated

29 August 2026, 01:50 UTC

Intake noted: Estimated allowed amount was specified as $2,940.00. Multiple diagnosis codes were provided (R06.00 and R93.1); R06.00 was extracted as primary. Date of service was stated as 'Requested, not yet performed'.

No threats found in the source document. Detectors that ran: rules, model_armor:enabled, gemma.

Personal data seen

None recorded — expected in a denial letter; recorded, not blocked.

Screened content hash

33e1b26ff8f459b2…

All 10 recorded invocations below belong to one trace. Every row is a span under it, including the drafting attempts Verification sent back.

Trace 4f31307dff20624c0657e7830b5a9021