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Post-pay review · Gulf Coast Diagnostic Imaging

Medicaid Member MBR-64220518 DOS 05 Mar 2026 Paid 19 Mar 2026 · $254.18 Recovery window closes in 31 days
Eligibility: Active on the date of service Superior HealthPlan STAR+PLUS · Texas Prior auth: Not required for this study under the state plan Advanced imaging
Review determination letter

As paid vs. as it should have been

Overpaid $254.18
LnCodeDescription PaidShould be VarianceResult
1 72148 MRI, lumbar spine, without contrast material
M54.50 · Low back pain, unspecified
$254.18 $0.00 $254.18 Not covered

Determination

2 of 3 layers

Separated so a provider can dispute the layer they disagree with, and so a reviewer can see which question was decided.

Coding defect Whether the code, level, units or sequencing follow the coding rule.

No coding defect. The code, the units and the sequencing are what the claim should carry; the disagreement is not about coding.

Clinical-evidence defect Whether the record supports the condition or service that was coded.
MNC
Repeat lumbar MRI 44 days after the prior study, with no documented change in clinical status
CPP-070 v1.3 allows a repeat study of the same region within 90 days only where the record documents a change in clinical status. The referring note repeats the prior history verbatim and records no new deficit, no new injury and no failed course of treatment since the January study. The diagnosis submitted, M54.50, is the same unspecified low back pain that supported the first study.
Decisive Edit
Payment consequence What it costs, and how the recoverable amount is computed.
AMT
$254.18 recoverable in full
A study that does not meet the coverage criterion is not payable at a reduced rate — there is no lower-level study to reprice to. The full paid amount is recoverable.
$254.18 Edit
Context, not part of the determination

These inform the reviewer. None of them is a reason the claim is wrong, and presenting them beside the defect is how an advisory becomes an allegation.

PAT
4 of this provider's last 41 claims were flagged
A 9.8% flag rate against an 8% peer group rate, 63rd percentile for the specialty. Advisory only; it is not a reason this claim is wrong.
Advisory

How it was coded

Coded as documented
Billed 72148 · MRI lumbar spine without contrast
Supported by the record 72148 · MRI lumbar spine without contrast

Remedy: None — the code, the unit count and the site of service are what the record supports

Reviewed for level, unit count, modifier and site. Nothing is wrong with how this study was coded. The disagreement is about whether the study should have been performed at all, which is a clinical question, not a coding one.

Prior authorization

Not required for this study under the state plan
Requirement Not required for this study under the state plan

This is why the finding is reachable. Under CPP-085 v3.4 an approved authorization bars post-service medical-necessity review of the authorised service; with no authorization on file that bar does not apply, and the criterion in CPP-070 is reviewable after payment. Had the provider obtained one, this review would have been limited to coding and pricing — both of which are correct.

Policy applied

Knowledge Center

Resolved as at the date of service, 05 Mar 2026 — not as at today.

CPP-070 Advanced imaging — medical necessity and site of service Decisive

The repeat-imaging criterion that this study fails, in the version in force on the date of service

In force on 05 Mar 2026: v1.3 effective 2025-04-01

No source document for v1.3 is in the index, so this policy can be cited here but not quoted. Upload it.

CPP-080 Eligibility, enrolment and retroactive termination Supporting

Coverage on the date of service, and the re-verification at audit

In force on 05 Mar 2026: v6.1 effective 2026-01-01

v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.

CPP-085 Prior authorization and post-service review Supporting

Why a post-service medical-necessity review is open here — there is no authorization on file to close it

In force on 05 Mar 2026: v3.4 effective 2025-11-01

v3.4 was extracted from CPP-085_prior-authorization-post-service-review_v3.4.md. Passages are quoted only on the policy the finding rests on.

Source document

Open all four views
837P_20260308_495425.edi
Availity clearinghouse · EDI 837P · received 08 Mar 2026 11:24 · claim control CCN-7610575933
Claim form As received EDI Remittance

How this was decided

Open the full trace

Walked through Professional claims post-pay review v1.9, signed off 2026-01-14.

Procedure SOP-PRO-01 — Professional claims — office visits, procedures, laboratory, imaging
Nodes walked 12
Model calls 0 — every node that resolved did so on a rule, a lookup or arithmetic
20 Jan 09:40 Prior lumbar MRI performed, same member, same region Claim history
05 Mar 08:15 Repeat lumbar MRI performed Gulf Coast Diagnostic Imaging
19 Mar 10:20 Claim paid, $254.18 released to provider Payment cycle
02 Apr 18:03 Selected by advanced imaging review Autonomize
07 Apr 11:15 Finding drafted for review — clinical layer only Autonomize