Sample output · de-identified
One case, start to finish.
The denial that arrives, the action plan that goes to the physician, and the appeal package that goes back to the plan. Real output, synthetic patient, health-system identifiers removed — and the denial letter is a constructed example, not correspondence from any payer.
Prior Authorization Request
Bariatric Surgery (CPT 43644)
This request is submitted in accordance with the applicable UnitedHealthcare medical policy governing the requested service. Each governing criterion is mapped below to contemporaneous clinical documentation.
Source · uhcprovider.com policy · bariatric surgery, medical necessity requirements, rev. 06/2026I certify that the information provided in this request is accurate and complete to the best of my knowledge, and that the requested service is medically necessary for this patient based on the clinical evidence cited above.
Every criterion is stated in the payer’s own words, then matched to a dated document in the chart. A reviewer can open both sides.
Match confidence is a number about our own retrieval, not about the patient. It belongs in the worklist, where a specialist uses it to decide what to check — anything under threshold is routed to them rather than asserted here. Printing it beside a criterion in the outbound package would only hand the reviewer a reason to discount the criterion. A criterion either made it into this document or it did not.
Synthetic patient, placeholder NPIs, health-system name and contact details removed. Nothing on this page came from a real chart.