Insurance Prior Authorization

Authorization requests carry four blocks: patientInfo.insuranceType (limited by the schema to Medicaid, Medicare, or Commercial), an array of diagnosisCodes, a serviceType, and serviceDetails holding the billing code, cost, and emergency flag.

Carrier routing happens before any rule fires: patientInfo.insuranceType == 'Medicaid' takes the first branch, 'Medicare' the second, 'Commercial' the third, and an unconnected isDefault statement catches unrecognized carriers. Splitting by payer up front keeps each ruleset small enough to be owned by the team that manages that contract.

Cost thresholds do most of the work in the Medicaid branch: 'Medication' over 200 and 'Procedure' over 500 require authorization, 'Equipment' over 300 triggers the 'DME over threshold' reason, and 'Imaging' requires authorization at any price since its serviceDetails.cost cell is empty. The final blank row returns requiresAuthorization false with the standard-service reason, and under the first hit policy it only fires when no service-specific row matched.

State Medicaid programs run on constrained budgets and lean on utilization management harder than most payers, so dollar-threshold gates and blanket prior authorization for imaging are realistic levers. Durable medical equipment gets its own threshold because DME is a recurring focus of Medicaid program-integrity reviews; the specific 200/500/300 amounts are sensible plan-level choices rather than mandated figures.

Procedure codes, not prices, drive this branch. A 'Medication' whose code contains 'J' is flagged as a 'Part B medication', 'Imaging' codes that start with 'CT' or 'MRI' count as advanced imaging, and the 'Procedure' and 'Equipment' rows convert the code with number($) and compare it against 1000 and 500. Anything else drops to the blank row and clears as a standard Medicare service.

J-codes are real HCPCS billing codes for drugs administered in clinical settings, which is the population Medicare Part B actually covers, and singling out CT and MRI mirrors how utilization management concentrates on advanced imaging rather than plain films. Treating the code itself as a number in the procedure and equipment rows is a simplified stand-in for the code-range lookups a production Medicare ruleset would maintain.

Explicit code lists define the commercial checks: 'Medication' codes containing 'SPE' mark specialty drugs, 'Procedure' matches the contiguous CPT block 33361 through 33364, and 'Imaging' matches 70450 through 70553, the head CT and brain MRI families that include the sample request's 70551. 'Equipment' switches back to a serviceDetails.cost > 1000 test, and two closing rows clear everything else: serviceDetails.isEmergency == true returns false with the emergency reason, and the final blank row clears standard services.

Specialty-drug gating and short lists of high-cost procedures are the standard shape of commercial utilization management, and 33361 to 33364 are genuine transcatheter aortic valve replacement codes, the kind of intervention plans review case by case. The emergency carve-out reflects the prudent layperson standard that governs emergency coverage under the ACA, though in this table it only applies once no specific code rule has already fired.

After the carrier tables run, this override scans the diagnosisCodes array with some() expressions: codes starting with 'Z51', the encounter-for-chemotherapy prefix, flip requiresAuthorization back to false, as do the O09.51 supervision-of-pregnancy codes, and 'U07.1' does the same when the second column confirms serviceType == 'Imaging'. Each exemption row also requires requiresAuthorization == true, and the final row passes requiresAuthorization and authorizationReason through untouched.

Layering exemptions after the payer tables means they hold regardless of carrier, which is how clinical carve-outs work in practice: oncology and pregnancy care are time-sensitive, and delaying them for paperwork is a common target of prior-authorization reform. The codes are real ICD-10 entries, Z51 for chemotherapy encounters, O09.51 for supervision of pregnancy, and U07.1 as the COVID-19 diagnosis code, so coders can maintain the exemption list without touching payer logic.

Output shrinks to three keys because passThrough is off: requiresAuthorization, the human-readable reason, and a timestamp set with date('now'). Recording when the determination was made matters for prior-authorization audit trails, where decision turnaround times can be contractually and legally bound.