# Examples — Prior Authorization Agent

## Complete request → assemble a review-ready packet

A request that meets every documented payer requirement. The agent assembles the packet — explicitly as a completeness status, not an approval.

**Input**

```
Request REQ-8841: MRI lumbar spine (72148), payer Acme Health. Attached: clinical note (2026-06-12), 6-week conservative-treatment record, prior X-ray report, signed order.
```

**Output**

```
{
  "payer": "Acme Health",
  "service": "MRI lumbar spine (CPT 72148)",
  "administrative_status": "READY",
  "requirements_checked": [
    { "item": "Conservative treatment >= 6 weeks documented", "present": true, "source": "PT record 2026-04-30 to 2026-06-11" },
    { "item": "Recent clinical note", "present": true, "source": "Office note 2026-06-12" },
    { "item": "Prior imaging report", "present": true, "source": "Lumbar X-ray report 2026-05-20" },
    { "item": "Signed order", "present": true, "source": "Signed order 2026-06-12" }
  ],
  "missing": [],
  "packet": "Assembled in Acme Health PA structure: cover sheet + 4 required documents (REQ-8841-packet)",
  "phi_note": "Only minimum-necessary PHI was used.",
  "human_note": "Packet is administratively complete and ready for staff review and submission.",
  "escalation": { "needed": false, "to": "none", "reason": "" },
  "disclaimer": "Administrative completeness check only — not a coverage or medical-necessity determination."
}
```

**Note:** Note the careful framing: 'READY' is an administrative completeness status, and the disclaimer makes explicit this is not an approval or a necessity determination. The agent matched each documented requirement to a source and assembled the packet for a human to submit.

## Missing document → precise gap list, hold

The request is almost complete but missing one payer-required item. The agent names exactly what's needed rather than guessing or proceeding.

**Input**

```
Request REQ-8907: MRI lumbar spine (72148), payer Acme Health. Attached: clinical note (2026-06-14), prior X-ray report, signed order. No conservative-treatment documentation found.
```

**Output**

```
{
  "payer": "Acme Health",
  "service": "MRI lumbar spine (CPT 72148)",
  "administrative_status": "INCOMPLETE",
  "requirements_checked": [
    { "item": "Conservative treatment >= 6 weeks documented", "present": false, "source": "" },
    { "item": "Recent clinical note", "present": true, "source": "Office note 2026-06-14" },
    { "item": "Prior imaging report", "present": true, "source": "Lumbar X-ray report" },
    { "item": "Signed order", "present": true, "source": "Signed order 2026-06-14" }
  ],
  "missing": ["Documentation of >= 6 weeks of conservative treatment (e.g. PT records or provider notes covering the period)"],
  "packet": "",
  "phi_note": "Only minimum-necessary PHI was used.",
  "human_note": "Hold submission. Request the conservative-treatment documentation from the ordering provider; once attached, re-run for packet assembly.",
  "escalation": { "needed": false, "to": "staff", "reason": "" },
  "disclaimer": "Administrative completeness check only — not a coverage or medical-necessity determination."
}
```

**Note:** Rather than submitting an incomplete packet (a common denial cause) or fabricating the missing record, the agent names the exact missing item and the likely source, and holds. This is the bread-and-butter time-saver: precise gap-chasing instead of manual checklist review.

## Clinical-judgment question → escalate to a clinician

A requirement hinges on a medical-necessity interpretation. The agent refuses to make the clinical call and escalates.

**Input**

```
Request REQ-9012: a payer rule for this procedure requires that 'imaging is medically necessary given failed conservative therapy and progressive neurological deficit.' The chart shows conservative therapy and some new symptoms, but whether they constitute a 'progressive neurological deficit' is a clinical interpretation.
```

**Output**

```
{
  "payer": "Acme Health",
  "service": "Advanced imaging (per payer necessity rule)",
  "administrative_status": "ESCALATE",
  "requirements_checked": [
    { "item": "Conservative therapy documented", "present": true, "source": "PT + provider notes" },
    { "item": "Clinical determination: progressive neurological deficit", "present": false, "source": "requires clinician interpretation" }
  ],
  "missing": [],
  "packet": "",
  "phi_note": "Only minimum-necessary PHI was used.",
  "human_note": "A clinician must determine whether the documented symptoms meet the payer's 'progressive neurological deficit' / medical-necessity criterion. I have prepared the administrative documents but cannot and will not make this clinical determination.",
  "escalation": { "needed": true, "to": "clinician", "reason": "Requirement depends on a medical-necessity / clinical interpretation, which is outside administrative scope." },
  "disclaimer": "Administrative completeness check only — not a coverage or medical-necessity determination."
}
```

**Note:** The crucial boundary example: the payer requirement turns on a clinical interpretation (is this a 'progressive neurological deficit'?), so the agent stops and routes it to a clinician. It explicitly states it cannot and will not make the medical-necessity call — exactly the line an administrative agent must hold in a regulated setting.
