The Medical Necessity API helps determine what documents are required for a medical procedure to be deemed medically necessary. It checks if the provided information is sufficient or if additional documentation is needed for the approval process. This API is particularly helpful in the authorization process by ensuring all necessary records and information are available to facilitate the review.

Endpoint

POST /api/v1/medical/necessity

Input Parameters

• HCPCS/CPT code: The code for the medical procedure or service being requested.
• Patient documents: A list of documents related to the patient’s condition or treatment (e.g., MD notes, scans, reports).

API Response

The response includes a list of documents that are required to meet medical necessity standards, along with a flag indicating any missing documents that are needed for the authorization process.

Example Request

{
  "hcpcs_code": "J0897",
  "documents": ["md_notes_pdf_url", "scan_report_pdf_url"]
}

Example Response

{
  "required_documents": ["Lab Report", "Physician Notes"],
  "missing_documents": ["Physician Notes"]
}

Response Codes