CASE-008

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Submission status

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Billing clerk

Confirms the paper trail: that the cited sections exist, that the quoted policy text matches its source, and that no claim outruns the matrix.

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Ordering clinician

Attests to the clinical argument: that the letter's account of the care and the chart is accurate. A clerk is not in a position to judge this.

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Open the clinical review screen for the ordering clinician

What this system has learned about NORTHBECK HEALTH PLAN

No prior appeals are on record against NORTHBECK HEALTH PLAN on this policy and reason code. This is the first one, or the earliest this system has seen.

Recorded from every case sharing this payer, policy and denial reason code -- never from this case's own patient data.

What the letter claims, and the policy text behind it

This letter cites no policy section

An appeal with no citation is an opinion, and there is nothing here to check against the insurer's own policy text.

The rest of the record

How this letter got here — 0 attempts

An attempt that verification sent back is shown here in full: the system catching its own error is evidence, not something to hide. This draft has not been verified: no citation or grounding check has run against it.

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The full criteria mapping — 11 criteria, 4 satisfied

The patient is an 83-year-old woman presenting with progressive exertional dyspnoea. An initial evaluation including a 12-lead ECG and a transthoracic echocardiogram was completed in March 2026. The echocardiogram was technically limited and inadequate to resolve the clinical question of septal thickening, leaving a differential between infiltrative cardiomyopathy and ischemic heart disease. The cardiac MRI is requested to distinguish these conditions and guide specific management steps. However, the patient has a permanent pacemaker, and the records show that its MRI compatibility remains unconfirmed and outstanding.

Whether the chart documents what the payer's own policy asks for. This is a documentation judgement, not a clinical one. There is no confidence column: a clerk cannot act differently at ninety-four percent than at eighty-eight, and there is no third thing they do at one hundred. Read the evidence.
Criterion	Verdict	Chart evidence
NBH-CARD-014-3.1 The member has symptoms consistent with cardiac disease, including but not limited to chest pain, dyspnoea on exertion, syncope, or palpitations, that have persisted for at least six weeks, or that are documented as progressive. Policy section NBH-CARD-014-3	Satisfied The patient has progressive exertional dyspnoea (shortness of breath on exertion) that has persisted for more than six weeks and is documented as progressive.	Eighty-three year old woman reporting six weeks of increasing breathlessness on exertion. enc/2026-02-18/internal-medicine Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. enc/2026-04-22/cardiology
NBH-CARD-014-3.2 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. Policy section NBH-CARD-014-3	Satisfied A 12-lead electrocardiogram and transthoracic echocardiogram were both completed in March 2026, within the 12 months preceding the June 2026 request.	Twelve-lead electrocardiogram performed 2 March 2026. enc/2026-03-02/ecg Transthoracic echocardiogram performed 9 March 2026. enc/2026-03-09/echocardiogram
NBH-CARD-014-3.3 The results of the initial evaluation under section 3.2 are inconclusive, equivocal, or technically inadequate for the clinical question posed, and the treating clinician has documented what remains unresolved. Policy section NBH-CARD-014-3	Satisfied The echocardiogram is documented as technically inadequate due to poor acoustic windows, and the clinician outlines that the differential between an infiltrative process (amyloidosis) and ischaemic heart disease remains unresolved.	The echocardiogram is technically inadequate for the clinical question. Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. NT-proBNP 1840 and a mildly raised high-sensitivity troponin support a cardiac cause. The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically. enc/2026-04-22/cardiology
NBH-CARD-014-3.4 The requested study is expected to change clinical management, and the treating clinician has documented the specific management decision that depends on the result. Policy section NBH-CARD-014-3	Satisfied The cardiologist documents that the cardiac MRI results will directly guide management: a positive amyloid pattern will lead to disease-modifying therapy after confirmatory tests, whereas an ischaemic pattern will lead to invasive angiography.	Cardiac magnetic resonance with late gadolinium enhancement and T1 mapping is the study that distinguishes these, and the distinction determines management directly: a positive amyloid pattern would take her to bone scintigraphy and serum free light chains and, if confirmed, to disease-modifying therapy, whereas an ischaemic pattern of enhancement would take her to invasive angiography. enc/2026-04-22/cardiology
NBH-CARD-014-3.5 There is no contraindication to magnetic resonance imaging, or, where a relative contraindication exists, the medical record documents that it has been addressed. Policy section NBH-CARD-014-3	Not satisfied The patient has a permanent dual-chamber pacemaker in situ, which is a relative contraindication. The medical record explicitly states that this conditionality has not yet been addressed and remains outstanding.	Did not address the pacemaker's MRI conditionality in this letter; that detail was not obtained before the appeal was filed and remains outstanding. enc/2026-06-25/cardiology-appeal-letter
NBH-CARD-014-4.1 The member presents with stable chest pain and an intermediate pre-test probability of coronary artery disease, as documented by a validated risk assessment tool. Policy section NBH-CARD-014-4	Not satisfied The patient presents with progressive exertional dyspnoea and is explicitly documented to have no chest pain, meaning she does not present with stable chest pain.	No orthopnoea, no chest pain, no syncope. enc/2026-02-18/internal-medicine
NBH-CARD-014-4.2 The member has not undergone coronary revascularisation, and no coronary stent is in place, unless the requested study is for the evaluation of graft patency. Policy section NBH-CARD-014-4	Not satisfied The patient's problem list notes a history of coronary artery bypass grafting, which is a coronary revascularisation procedure.	No chart evidence cited
NBH-CARD-014-4.3 The member's heart rate is expected to be controllable to a rate suitable for the acquisition, or the imaging facility has documented capability for high-heart-rate acquisition. Policy section NBH-CARD-014-4	Insufficient documentation The record is silent regarding the controllability of the patient's heart rate or the imaging facility's high-heart-rate acquisition capabilities.	No chart evidence cited
NBH-CARD-014-6.1 Advanced cardiac imaging performed solely for screening in an asymptomatic member, absent a documented high-risk inherited cardiomyopathy in a first-degree relative. Policy section NBH-CARD-014-6	Not satisfied The patient is symptomatic, with progressive exertional dyspnea and orthopnea, meaning the imaging is not being performed solely for screening in an asymptomatic member.	Her symptoms have progressed further since February; she now stops three times on the same walk and has developed mild orthopnoea. enc/2026-04-22/cardiology
NBH-CARD-014-6.2 Repeat advanced cardiac imaging of the same anatomical territory within twelve months of a prior diagnostic-quality study, absent a documented interval change in clinical status. Policy section NBH-CARD-014-6	Not satisfied The patient has not undergone a prior diagnostic-quality advanced cardiac imaging study of the same territory within the past twelve months. Her prior transthoracic echocardiogram was technically inadequate and of poor image quality.	Transthoracic echocardiogram performed 9 March 2026. Image quality is poor secondary to body habitus and limited acoustic windows; the apex and the lateral wall are not adequately visualised. enc/2026-03-09/echocardiogram The echocardiogram is technically inadequate for the clinical question. enc/2026-04-22/cardiology
NBH-CARD-014-6.3 Advanced cardiac imaging performed for research purposes or as part of a clinical trial protocol funded by the trial sponsor. Policy section NBH-CARD-014-6	Not satisfied The requested cardiac magnetic resonance imaging is for active clinical diagnostic purposes and to directly guide medical management, rather than for research purposes or clinical trial protocols.	The differential is between an infiltrative cardiomyopathy, most importantly cardiac amyloidosis given her age and the septal appearance, and ischaemic disease that the paced rhythm prevents me from excluding electrocardiographically. Cardiac magnetic resonance with late gadolinium enhancement and T1 mapping is the study that distinguishes these, and the distinction determines management directly enc/2026-04-22/cardiology

3 criteria could not be evaluated at all: NBH-CARD-014-5.1, NBH-CARD-014-5.2, NBH-CARD-014-5.3 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.

The denial letter as received — 1 line item

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 original determination is UPHELD. Coverage for the service listed above remains DENIED. ... The reviewer concurs with the original determination that the submitted records do not establish that a contraindication to magnetic resonance imaging has been addressed: the record identifies a permanent pacemaker without stating whether the device is MRI-conditional, and the appeal submission did not supply this information. On that basis the reviewer upholds the denial of cardiac magnetic resonance imaging and did not reach the remaining criteria under NBH-CARD-014-3.

Reason code NBH-NMN-11-A1

Date of denial

24 July 2026

Appeal deadline

20 January 2027 · 82 days remaining

Appeal level

first level appeal

Last updated

29 August 2026, 17:32 UTC

Intake noted: Estimated allowed amount listed as $2,940.00 but no billed amount specified. Diagnosis codes submitted were R06.00 and R93.1; R06.00 was extracted as primary. Date of service was stated as 'Requested, not yet performed'.

Audit trail — 4 recorded events, 1 trace

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: 8e65e32d08c02f7b…

All 4 recorded invocations below belong to one trace. Every row is a span under it, including the drafting attempts Verification sent back.

Trace 63e9378d28a7783e724fc10875e4b978

When	Agent	Operation	Decision
29 August 2026, 17:31 UTC	sentinel	screen span ea1a7a7751a71703	clean (rules, model_armor:enabled, gemma)
29 August 2026, 17:31 UTC	intake	extract span c14e0c583f73c883	1 service(s) via text layer; appeal deadline 2027-01-20
29 August 2026, 17:31 UTC	retrieval	reformulate span 8319281657471f61	retrieved NBH-CARD-014 (7 sections, 14 criteria) at similarity 0.066 after reformulation
29 August 2026, 17:32 UTC	mapping	map_section span a1908b313e55b632	11 criteria evaluated (1 insufficient_documentation, 6 not_satisfied, 4 satisfied); appealable basis: False; 3 verdict(s) adjusted in validation; 3 criteria not evaluated