Introduction

Backwork turns Medicare and commercial payer coverage policies into structured data: which policies apply to a code, whether prior authorization is required, the coverage criteria, and what changed. You call it over a REST API or from an AI client through MCP.

Production availability of the endpoints on this page

Get started

Sign up free at backworkhealth.com. Your organization gets 100 free starter credits, and you create a live key yourself in API usage and keys. When you need more, buy a Credits pack ($20 for 1,000 requests) or start a monthly pack on the same page.

What Backwork does

Coverage policies are spread across CMS documents, Medicare contractor publications, and commercial payer portals, mostly as PDFs. Backwork extracts coverage criteria, prior-authorization requirements, and code lists from Medicare LCDs, Articles, and NCDs and from commercial payer policies, and serves them as JSON with a link to each source document.

Every code linked to a policy says where the link came from: the policy document lists it (document), or Backwork inferred it from the policy title (inferred_title_match). See Code sources.

Your first request

curl "https://backworkhealth.com/api/v1/codes/lookup?code=99213&include=policies" \
  -H "Authorization: Bearer $BACKWORK_API_KEY"

The Quickstart shows the response.

Common tasks

Check whether a procedure needs prior authorization

curl -X POST "https://backworkhealth.com/api/v1/prior-auth/check" \
  -H "Authorization: Bearer $BACKWORK_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{"procedure_codes": ["27447"], "state": "TX"}'

The response lists the matching policies, the coverage status, and the documentation the policies ask for. See checkPriorAuth.

Compare coverage across MAC jurisdictions

Medicare coverage varies by MAC jurisdiction: a procedure covered in one can have different criteria in another.

curl -X POST "https://backworkhealth.com/api/v1/policies/compare" \
  -H "Authorization: Bearer $BACKWORK_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{"procedure_codes": ["76942"], "jurisdictions": ["J5", "J6", "JM"]}'

Review recent policy changes

curl "https://backworkhealth.com/api/v1/policies/changes?since=2026-09-01T00:00:00Z&limit=20" \
  -H "Authorization: Bearer $BACKWORK_API_KEY"

Look up many codes at once

curl -X POST "https://backworkhealth.com/api/v1/codes/batch" \
  -H "Authorization: Bearer $BACKWORK_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{"codes": ["99213", "E11.9", "27447"], "include": "policies"}'

Search commercial formulary evidence

Search pharmacy-benefit evidence from CVS Caremark, Express Scripts, and UnitedHealthcare / Optum Rx:

curl "https://backworkhealth.com/api/v1/drugs/formulary?q=metformin&payer=all&limit=5" \
  -H "Authorization: Bearer $BACKWORK_API_KEY"

Each record names its source and includes tier, coverage status, utilization management requirements, alternatives, and the source URL.

Export as CSV or FHIR

Policy endpoints return JSON by default, CSV with format=csv, and FHIR R4 CoverageEligibilityResponse resources with format=fhir:

curl "https://backworkhealth.com/api/v1/policies?icd10=E11.9&format=csv" \
  -H "Authorization: Bearer $BACKWORK_API_KEY"

Limits

• Backwork covers Medicare LCDs, Articles, and NCDs and the commercial payer policies it has collected. It does not cover state Medicaid policies.
• The API returns what the policies say. It does not make coverage decisions for you.
• Confirm codes with source: "inferred_title_match" against the policy document before you rely on them.

Resources

• API reference: every endpoint
• SDKs and HTTP clients: call the API from any language, or generate a typed client
• Authentication: keys and scopes
• Pricing and credits: packs and request costs
• Rate limits: per-minute limits and headers
• Errors: every error code and whether to retry
• Build with AI: Markdown docs, llms.txt, and what an agent should check

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