Identify the coverage framework
Determine the payer and product—such as Traditional Medicare, Medicare Advantage, Medicaid or commercial coverage—because different requirements may apply.
Identify applicable regulatory and coverage requirements
Evaluate relevant law, CMS guidance, NCDs, LCDs, state requirements, contractual requirements and health-plan policies.
Apply appropriate clinical decision support
Use client-approved clinical decision-support criteria, when applicable, to structure the clinical review.
Consider specialty guidance and evidence
Consult authoritative specialty recommendations or evidence when the clinical question requires additional depth.
Evaluate the individual patient
Assess presenting illness, objective findings, comorbidities, treatment, response, clinical trajectory, risk and expected course.
Document a clear physician rationale
Explain why the applicable facts and standards support the final determination.
COPD inpatient review
Coverage → criteria → clinical severity → expected hospital course → applicable regulation → physician judgment → documented rationale.
This prevents the review from being reduced to a single checkbox and keeps the analysis tied to the actual clinical record.