CMS Medicare Advantage rules, 42 CFR 422.101(c)(1)(i) and 422.566(d)

Example (Python + Anthropic SDK), before:

features = {'cpt': req.cpt, 'icd10': req.icd10, 'cohort_approval_rate': cohort_stats(req.icd10)}
reply = client.messages.create(model=MODEL, max_tokens=400,
    messages=[{'role': 'user', 'content': f'Prior authorization request: {features}'}])

After:

record = member_clinical_record(req.member_id, fields=PA_CLINICAL_FIELDS)   # history, conditions, meds
submission = provider_clinical_submission(req.id)                            # notes, letter of medical necessity
if not record or not submission:
    return review_queue.enqueue(req.id, reason='individual clinical information missing')
reply = client.messages.create(model=MODEL, max_tokens=400, messages=[{'role': 'user', 'content':
    render('pa_review.txt', request=req, clinical_history=record, provider_submission=submission)}])
determinations.save(req.id, inputs={'clinical_history': record.ids, 'submission': submission.ids})

Example (Python + OpenAI SDK (prior-authorization service)), before:

result = client.chat.completions.create(model=MODEL, messages=build_pa_prompt(request)).choices[0].message.content
if json.loads(result)['decision'] == 'deny':
    prior_auth.update(request.id, status='denied')
    send_denial_letter(request)

After:

result = json.loads(client.chat.completions.create(
    model=MODEL, messages=build_pa_prompt(request, record=member_clinical_record(request))).choices[0].message.content)
if result['decision'] == 'approve' and AUTO_APPROVE_ALLOWED:
    prior_auth.update(request.id, status='approved', ai_assisted=True)
else:                                   # any non-approval goes to a clinician
    review_queue.enqueue(request.id, queue='pending_clinical_review',
                         specialty=request.specialty, ai_recommendation=result)

@app.post('/reviews/{case_id}/decision')
def record_clinical_decision(case_id: str, body: Decision, reviewer=Depends(licensed_clinical_reviewer)):
    decision = clinical_decisions.create(case_id=case_id, reviewer_id=reviewer.id, licence=reviewer.licence,
                                         specialty=reviewer.specialty, documents_reviewed=body.documents,
                                         outcome=body.outcome, rationale=body.rationale)
    if body.outcome in ('denied', 'downgraded'):
        send_adverse_determination(case_id, decision=decision, signed_by=reviewer)