What the provider receives

A determination that says only “unsupported” cannot be answered: the provider cannot tell which question was decided, so the appeal addresses the wrong one and the reviewer has nothing to audit. This letter separates the three questions, numbers them, and says what would overturn each.

Back to the audit Reasoning trace

Drafted by Autonomize · not sent

Overpayment notice — Gulf Coast Diagnostic Imaging

$254.18

Re: claim CLM-0000025 · member MBR-64220518 · date of service 05 March 2026

A post-payment review of the claim above identified $254.18 as recoverable. The review separates three questions, and each is answered in its own numbered section below. Each section can be disputed on its own; disputing one does not put the others in issue.

Policy basis

This review applied each policy as it stood on 05 Mar 2026, the date of service, not as it stands today. No policy cited below has changed since then, so the current version and the governing version are the same document.

1 Coding Was the service coded according to the coding rule? Nothing found

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

2 Clinical documentation Does the record support the service that was coded? Finding

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.

CPP-070 v1.3 Advanced imaging — medical necessity and site of service

To dispute section 2 Submit the part of the medical record for 05 Mar 2026 that documents what the billed code requires. The review was conducted on the documentation submitted with the claim; anything not sent with it was not seen.

3 Payment What, if anything, is recoverable? Finding

$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.

Line	Code	Paid	Allowable	Recoverable
1	72148 1 × per site	$254.18	$0.00	$254.18

Priced against

The 2026 fee schedule allows $254.18 for 72148 in a non-facility setting: total 7.61 RVU at a conversion factor of 33.4009. CMS Physician Fee Schedule 2026, TX locality 09

To dispute section 3 There is no separate payment argument to make here. The amount follows from section 2: the service was not payable at a reduced rate, so if section 2 is overturned nothing is recoverable, and if it stands the full amount is. Argue section 2.

Your rights

You may dispute any section on its own. Name the section number and send what that section asks for; the other sections are unaffected.
Submit a dispute within 30 days of the date of this notice and payment activity is held pending review.
You may instead remit the amount above within 30 days, or notify us in writing that you elect offset against future payments.

Payment Integrity · 1-800-000-0000 · recoveries@example.org

What the agent did not do

Said on the letter itself, not only here. The case for putting an agent this close to a recovery rests on where it stops.

This letter was drafted by the review and has not been sent.
No recoupment has been taken and no offset has been applied.
No provider record was corrected and no authorization was changed.
A named reviewer signs, or does not.

Every figure is derived

The addressing — who it is to, which claim, the phone number — comes from the audit book. Everything that asserts something is computed from the claim when the page is built: the amount is the sum of the line variances, the sections are the finding's own layers, and the policy version is resolved at the date of service. A seeded sentence can drift from the claim it describes. This cannot.

Sections in dispute

Each is answered separately. A provider who disputes one does not put the others in issue, and the analyzer routes their argument to the section it actually contests.

1 Coding

nothing found — not in issue

2 Clinical documentation

separately appealable

3 Payment

decided by section 2

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