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Prior Authorization Review

Request Summary

Patient: X23F2

Procedure: Robotic-Assisted Peripheral Lung Biopsy (CPT 32405)

Provider: Dr. Sarah Chen, Pulmonology Associates

Submitted: December 18, 2025

Validation Checks

Provider NPI

Status: ✓ Verified

CPT Code (32405)

Status: ✓ Verified billable

ICD-10 (R91.1)

Status: ✓ Verified

Coverage Policy

Status: ✓ LCD L38319 applies

Medical Necessity (LCD L38319)

Pulmonary nodule on imaging

Documentation: 2.3cm spiculated nodule, RUL

Status: ✓ Met

Tissue diagnosis warranted

Documentation: PET SUV 4.2, concerning for malignancy

Status: ✓ Met

Surgical candidate

Documentation: FEV1 78% predicted

Status: ✓ Met

Less invasive approach tried

Documentation: Prior bronchoscopy non-diagnostic

Status: ✓ Met

Recommendation

APPROVE

All LCD L38319 criteria met. Provider verified.

Audit Trail

NPI lookup

  • Source: NPI Registry MCP

ICD-10 validation

  • Source: ICD-10 Database MCP

Coverage search

  • Source: CMS Coverage Database MCP

Documentation review

  • Source: Uploaded files

Prior authorization

Prior authorization reviews take hours of cross-referencing while patients wait. Claude flags documentation gaps, catches who's been overlooked, and drafts requests ready for review.

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Appeal Review Summary

Lumbar Spinal Fusion L4-L5

Appeal ID: APL-2024-0284719 | Member: UHC-8847291 (62F)

Procedure: Lumbar spinal fusion L4-L5 (CPT 22612, 22630)

Provider: James Morrison, MD | Review Due: January 17, 2025

Original Denial

Code: MN-401

Reason: Insufficient documentation of failed conservative treatment

Policy Reference: Section 4.2.1

Code: MN-403

Reason: Required interventional treatments not documented

Policy Reference: Section 4.2.3

Gap identified: ESI #3 procedure note was missing from original submission.

Policy Criteria Review

Failed conservative treatment ≥6 months

Evidence: 9 months documented

Status: ✅ Met

Trial of ≥2 NSAIDs

Evidence: Naproxen, Meloxicam

Status: ✅ Met

Physical therapy ≥12 sessions

Evidence: 18 sessions, documented plateau

Status: ✅ Met

≥3 epidural steroid injections

Evidence: 3 ESIs with diminishing relief

Status: ✅ Met

MRI within 90 days

Evidence: 10/28/24 (51 days prior)

Status: ✅ Met

Functional impairment

Evidence: ODI score 44 (threshold: >40)

Status: ✅ Met

Recommendation

APPROVE APPEAL

  1. ESI #3 procedure note now included — addresses primary gap from original denial
  2. All policy criteria met with supporting clinical documentation
  3. Progressive functional decline despite completed conservative pathway

Alternative Recommendations

Peer-to-peer review

Recommendation: Not required — documentation complete

Request additional records

Recommendation: Not required — all criteria addressed

Uphold denial

Recommendation: Not supported — gap resolved

Audit Trail

Original claim denied (MN-401, MN-403)

  • Date: 12/02/2024

Appeal received

  • Date: 12/18/2024

Recommendation: Approve

  • Date: 12/18/2024

Generated by Claude | Requires reviewer sign-off before member notification

Insurance claims appeals processing

Denied claims cost time and money for everyone. Claude helps providers build stronger appeals, and payers process them faster.

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Care coordination and patient messaging triage

Sort hundreds of patient messages a day in seconds. Claude identifies urgent issues, drafts responses for routine questions, and routes the rest to the experts.

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Clinical Documentation

Generated from visit recording | Dec 18, 2025 | 12:34 PM

Patient

[Name] | DOB: XX/XX/XXXX | MRN: 4892

Visit Summary

Chief complaint

Persistent cough and fatigue for 2 weeks

History of present illness

Patient reports dry cough beginning approximately 14 days ago, worsening over the past week. Associated fatigue and mild shortness of breath with exertion. Denies fever, chills, or night sweats. No recent travel or known sick contacts.

Physical Exam

Vitals: BP 128/82, HR 78, Temp 98.4°F, SpO2 97%

General: Alert, no acute distress

Lungs: Clear to auscultation bilaterally, no wheezes or crackles

Cardiac: Regular rate and rhythm

Assessment

  1. Acute bronchitis (ICD-10: J20.9) ✓
  2. Fatigue (ICD-10: R53.83) ✓

Plan

⚠️ REVIEW: Confirm benzonatate dosage - patient mentioned sensitivity to similar medications

☐ Benzonatate 100mg TID PRN cough x 7 days

☐ Rest and increased fluids

☐ Return if symptoms worsen or fever develops

☐ Follow-up in 2 weeks if not improving

Review Flags

⚠️ Medication: Confirm benzonatate dosage given patient history

⚠️ Billing: Verify E/M level matches documentation

Ready for signature: [Sign] [Edit] [Add addendum]

Connectors used: ICD-10 | NPI Registry

Generated in 47 seconds from 12-minute recording

Ambient scribing for clinical documentation 

With Claude's Developer Platform, health startups can build breakthrough products for medical scribing, chart reviews, and clinical decision support. Less time documenting, more time with patients.

Powering leading healthcare organizations

"We were drawn to Anthropic's focus on AI safety and Claude's Constitutional AI approach to creating more helpful, harmless, and honest AI systems."

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Mike Reagin, Chief Technology Officer, Banner Health

"For the first time, our researchers can truly converse with our datasets - scrutinizing treatment patterns, understanding real-world disease trajectories, and generating novel insights that simply weren't accessible before."

Allison Candido, Vice President & Head of Engineering, Flatiron Health

"Safety is non-negotiable in healthcare. Anthropic has been a clear leader in building models with strong safety foundations."

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Justin Norden, MD and co-founder, Qualified Health

"With Claude's suite of LLMs, we deliver the quality to automate clinical documentation at scale, saving clinicians millions of hours annually and returning their focus to patient care."

Dhruv Parthasarathy, Chief Technology Officer, Commure

"Carta Healthcare's implementation of Anthropic models via Amazon Bedrock has allowed for rapid and secure deployment of the newest models. Unlocking our hybrid intelligence AI system that is turning into a complete re-invention of understanding a patient's medical record for clinical data abstraction."

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Andrew Crowder, VP of Engineering, Carta Healthcare

"Commercial pharma teams are entering an era where real-time clinical intelligence and AI agents fundamentally change how therapies reach the right patients at the right time. Anthropic's models are unmatched in their reasoning capabilities and safety design. This collaboration accelerates our shared mission to ensure that clinical-grade agentic AI becomes a trusted, transformative force across global pharma."

Chris Mansi, MD, CEO and co-founder of Viz.ai

"We chose Claude, powered by Anthropic, for the strength of its model and its reputation for responsible AI. That balance of performance plus trust was a decisive factor."

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Kyna Fong CEO & Co-Founder, Elation Health

"At Pair Team, we're building the safety net of the future. Claude is accelerating how we design and ship software across healthcare and public assistance and shaping our architecture toward fully autonomous agents. That's what allows us to scale high-quality care management to millions who've historically been left out."

Neil Batlivala, CEO, Pair

"Claude handles the complex healthcare workflows our teams deal with daily accurately and securely. Our engineers are shipping faster, our consultants are delivering insights with unprecedented speed. When you're serving 4,400+ healthcare organizations, that combination of capability and velocity is critical."

David Zito, President Performance Services, Premier

"Claude's Agent SDK has unlocked a step-change in how we operate—converting rigid research processes into adaptive, compliant agents that scale across our organization. Coupled with the exceptional performance of Claude's models, it's accelerated our ability to discover, build, and deliver value. And with Claude Code streamlining our end-to-end development workflow, we're seeing faster execution, better alignment, and a significant uplift in overall team productivity."

Dr. Thomas Kelly, Co-Founder and CEO, Heidi Health

"Claude lets us punch way above our weight in healthcare AI. It powers our clinical extraction engine, cuts implementation timelines, and gives our GTM team dev-level capabilities. The faster we build, the faster clinics get out of manual chart review and back to patients."

Zach Rosen, CEO & Co-Founder, Brellium

"Home-based care is becoming the center of gravity in healthcare but the infrastructure was never built for it. Powered by Claude, our frontier AI reimagines how care is coordinated, governed, and delivered outside the hospital, turning fragmented processes into intelligent systems that can scale with patients' needs."

Vijay Kedar, Founder & CEO, Tomorrow Health
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Claude connects to your healthcare ecosystem

Coverage policies, coding systems, and clinical guidelines, all in one place.

Explore connectors

Built for healthcare

AI you can trust

Claude is built on HIPAA-ready infrastructure with safety guardrails designed for healthcare. Answers can be traced back to the source, so you can verify before you act.

Claude Developer Platform

Claude understands the complexity of medical coding, payer rules, and clinical decisions. It reviews your records and policies, then shows you where the answers came from. Work that took days now takes minutes.

Made for healthcare

Claude can connect to the data you need: CMS Coverage Database, ICD-10, NPI Registry, or PubMed. Sample skills give you a starting point to customize workflows with your organization's policies, data, and use cases.

Your partner in better care

We're investing in healthcare for the long term with a dedicated healthcare team, an expanding network of data partners like Function, HealthEx, Apple Health, Android Health Connect, and capabilities that grow with you.

Case study

Banner Health is tackling physician burnout with Claude. See how they built an AI platform that's helping physicians focus on patient care.

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Case study

Qualified Health uses Claude to identify patients who qualify for life-saving treatments but would otherwise go undetected.

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Case study

Elation Health reduced chart review time by 61% with Claude, helping primary care clinicians spend less time on documentation and more on patients.

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Case study

Carta Healthcare uses Claude to reduce clinical data processing time by 66% while achieving 99% accuracy.

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Livestream

Tune in to watch Anthropic CEO and Co-founder Dario Amodei share his vision for AI in healthcare and life sciences, along with an executive customer panel.

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Get started with Claude

Healthcare customers can access Claude via Claude for Enterprise and the Claude Developer Platform. 

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