Check it out...
Here is the link to the prototype.
https://huggingface.co/spaces/pilayar/provider-auth
I have prototyped for two specific procedures that require prior authorization: Spinal Fusion and Endoscopy.
To execute the prototype, you will need to copy and paste provider notes in the provider note section and then select the appropriate procedure. For reference I have four examples of clinician notes: Two for Spinal Fusion and two for Endoscopy, and for each one approval and one denial. You can copy the notes from below for easy reference:
Example 1 Spinal Fusion: Spinal Fusion missing Physical Therapy
Clinical Progress Note
Patient: Jane Doe
DOB: 05/12/1978
Date of Service: April 01, 2026
Provider: Dr. Aris Thorne, Orthopedic Surgery
Subjective:
Patient presents with chronic, debilitating lower back pain radiating down the left lower extremity (L5-S1 distribution). Pain intensity is 8/10. Patient reports that she "tried some exercises at home" and used OTC Ibuprofen with minimal relief. She is requesting surgical intervention as she is unable to sit for more than 20 minutes at her desk job.
Objective:
Physical Exam: Positive straight leg raise on the left. Diminished patellar reflex (1+).
Imaging (MRI): Significant disc herniation at L5-S1 with moderate neuroforaminal narrowing. No evidence of cauda equina syndrome.
Assessment:
Lumbar disc herniation with radiculopathy (M54.16).
Failed conservative management (per patient report).
Plan:
Procedure: L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).
Request: Submit prior authorization for CPT 22633.
Example 2 Spinal Fusion: Example 2 (Approval): Spinal Fusion
Patient: Jane Doe
DOB: 05/12/1978
Date of Service: April 07, 2026
Provider: Dr. Aris Thorne, Orthopedic Surgery
Subjective:
Patient returns for follow-up regarding chronic L5-S1 radiculopathy. Pain remains 8/10. Patient has completed 12 weeks of supervised Physical Therapy (Jan 5 – Mar 30, 2026) at City Rehab, focusing on core stabilization and McKenzie protocols. Despite 100% compliance, symptoms have progressed to include persistent numbness and "foot drop" during ambulation.
Objective:
Physical Exam: 3/5 strength in left EHL (Extensor Hallux Longus). Absent Achilles reflex (0) on left side. Positive straight leg raise at 30 degrees.
Imaging (MRI - Mar 15, 2026): Confirmed L5-S1 herniation with severe canal stenosis.
Medication History: Failed 4-week trial of Gabapentin (900mg TID) and two documented epidural steroid injections (dates: 02/10/26 and 03/05/26) with <20% relief.
Assessment:
Lumbar spinal stenosis with neurogenic claudication (M48.061).
Failed exhaustive conservative management (PT, injections, and pharmacological intervention).
Acute neurological progression (EHL weakness).
Plan:
Procedure: L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).
Request: Urgent Prior Authorization for CPT 22633.
Example 3: EGD: Pend EGD
Patient: Robert Miller
DOB: 11/22/1975
Date of Service: April 07, 2026
Provider: Dr. Sarah Chen, Gastroenterology
Subjective:
Patient presents with a 4-month history of "heartburn" and epigastric burning occurring 3–4 times per week, typically after heavy meals. He has been using over-the-counter Tums (antacids) as needed with temporary relief. Patient denies any difficulty swallowing (dysphagia), painful swallowing (odynophagia), or unintended weight loss. No history of GI bleeding or anemia. He is frustrated with the discomfort and is requesting a "scope" to see what is going on.
Objective:
Abdomen: Soft, non-distended. Mild tenderness to palpation in the epigastric region. No masses or organomegaly noted.
Vitals: Stable. BMI 31.
Labs: CBC within normal limits; Hgb 14.2 (no evidence of anemia).
Assessment:
Gastro-esophageal reflux disease (K21.9).
Epigastric pain (R10.13).
Plan:
Procedure: Schedule EGD with biopsy (CPT 43239).
Reason: Evaluation of persistent GERD symptoms.
Example 4: EGD: Example of Approved EGD
Patient: Robert Miller
DOB: 11/22/1975
Date of Service: April 07, 2026
Provider: Dr. Sarah Chen, Gastroenterology
Subjective:
Patient returns for evaluation of worsening epigastric pain and new-onset dysphagia (difficulty swallowing). He reports that solid foods (meat, bread) feel "stuck" in the mid-chest area several times a week. Patient also reports an unintentional weight loss of 12 pounds over the last two months. He has been 100% compliant with Omeprazole 40mg daily for the past 9 weeks with no improvement in symptoms.
Objective:
Physical Exam: Patient appears thin but not in acute distress. Abdomen is soft; mild epigastric tenderness noted.
Vitals: BP 118/76, HR 72. Weight: 172 lbs (down from 184 lbs on 02/01/2026).
Labs: CBC reveals mild microcytic anemia (Hgb 11.2, MCV 78), suggesting potential occult blood loss.
Assessment:
Dysphagia, oropharyngeal phase (R13.11): New onset, progressive.
Unintentional weight loss (R63.4): 6.5% of body weight in 60 days.
GERD, refractory (K21.9): Failed 2-month high-dose PPI trial.
Iron deficiency anemia (D50.9): Suspected GI source.
Plan:
Procedure: Urgent EGD with biopsy (CPT 43239) to rule out esophageal malignancy, Barrett’s Esophagus, or high-grade stricture.
Request: Prior Authorization required.