The submission packet
One document a reviewer can act on: what is proven, what is missing, and the single line that closes each gap.
Ready or action needed. Never a maybe.
A packet is marked action needed the moment any criterion is a gap, so nothing goes out half-supported. Below is the shape of the packet on the synthetic demo case.
Prior-auth packet (illustrative)
Right L5-S1 lumbar laminotomy with microdiscectomy (CPT 63030)
Aetna CPB 0743: Spinal Surgery (Laminectomy and Fusion), lumbar laminectomy for a herniated disc
What is blocking approval
C4c Active in-person physical therapy (not home or virtual) for the entire required duration, confirmed by the actual PT notes or by documentation in the member claims history
Fix Add documentation of in-person physical therapy (PT notes or member claims), then re-run.
Proven against the chart
- C1 All other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning
- C2 Member has signs or symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) associated with the levels being treated
- C3 Advanced imaging studies (CT or MRI) indicate central/lateral recess or foraminal stenosis (graded as moderate, moderate to severe or severe; not mild or mild to moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings
- C4a Member has failed at least 6 weeks of conservative therapy
- C4b Conservative measures were recent (within the past year)
- C4d Trial of medications (NSAIDs, acetaminophen, or tricyclic antidepressants)
- C4e Patient education provided
- C5 Member's activities of daily living are limited by symptoms of neural compression
What the packet carries
The decision
Ready when every criterion is proven, action needed otherwise.
The proven list
Each criterion beside the chart span that supports it.
The gap list
What is required, what is missing and how to close it.