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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.
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
- ESI #3 procedure note now included — addresses primary gap from original denial
- All policy criteria met with supporting clinical documentation
- 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.

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.
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
- Acute bronchitis (ICD-10: J20.9) ✓
- 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











Claude connects to your healthcare ecosystem
Coverage policies, coding systems, and clinical guidelines, all in one place.
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.

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