Case clearance
the pre-scheduling coverage-conditions gate · every report below is a real engine run with its receipt ·
→ coverage radar
demo date of service 2026-09-15 · engine 0.1.0 · clearance 0.1.0
FIXTURE-GRADE · synthetic demonstration cases · encoded from published primary sources, pending credentialed-reviewer validation · not a coverage determination · procedure names only, no CPT descriptor text · the engine consumes day-offsets, never patient dates
The moment this intercepts: a cardiac case is proposed for a date, before it reaches the OR or cath-lab schedule. The coverage conditions that decide whether it will ever be paid — waiting periods counted in calendar days, a shared-decision-making visit by the right kind of practitioner, heart-team documentation, registry participation — live today in coordinators' heads, static PDF checklists, and Excel.
The downside of missing one is not a rework loop. The Department of Justice recovered over $250 million from 457 hospitals for ICDs implanted inside the NCD waiting periods — miscounted calendar days. CMS is actively recouping LAAO and ICD claims where the SDM note wasn't in the chart before implant. Cape Cod Hospital paid $24.3M over TAVR heart-team documentation.
Case Clearance runs the same policy packs as the coverage radar against one proposed case and returns a verdict, the failed or unverifiable conditions with the policy text cited, the earliest compliant date when a waiting period fails, and a receipt. Rules decide; nothing here is a model's opinion.
evidence: DOJ press release 2016 (457 hospitals, $250M+) · CMS MLN Fast Fact on LAAC & ICD NCD documentation (CERT recoupments) · Noridian ACM Q&A 2026-03-05 (SDM practitioner question) · sources cited per-condition below
Five synthetic cases, each a documented failure mode. Every variant was evaluated by the WAFL engine ahead of this page's publication — the page renders stored engine output; it decides nothing in your browser.
The authority chain, resolved per cell. Medicare FFS routes to the NCD or the MAC-jurisdiction LCD for the patient's state. Humana Medicare Advantage routes to Humana's own policy shell, which defers by its own text to the governing NCD or nationalizes an LCD — an authority chain, never a borrowed answer. A commercial plan whose delegation or edition is unverified returns INSUFFICIENT FACTS, and says why.
Deterministic day-math. Dates enter the engine as day-offsets from the proposed date of service — no patient dates are stored or transmitted. When a waiting period fails, the report computes the exact earliest compliant date. Same case, same date, same answer, every time, with a sha256 receipt over the whole decision.
Honest unknowns. A condition nobody has verified renders as UNKNOWN with the action needed to resolve it. Zero checked conditions is never a clearance.